Foundation  in  Nursing 
Kducatlon 


OBSTETRICAL  NURSING 


A  Companion  Book 

GETTING  READY  TO  BE  A  MOTHER 

A  LITTLE  BOOK  OF  INFORMATION  AND 
ADVICE  FOR  THE  YOUNG  WOMAN 
LOOKING  FORWARD  TO  MOTHERHOOD 


BY 
CAROLYN   CONANT   VAN   BLARCOM,   R.N. 

WITH  AN   INTRODUCTION    BY 

J.    CLIFTON    EDGAR,     M.D. 

AND 

FREDERICK  W.   RICE,   M.D. 


Many  obstetricians  require  their  patients 
to  read  this  book 


"If  every  expectant  mother  followed  the  simple  practical 
advice  which  this  book  offers,  the  rate  of  injury  and  death 
among  our  mothers  and  babies  would  be  materially  lessened." 
—  From  the  Introduction  by  Doctors  Edgar  and  Rice. 

76  Illustrations  Price  $1.50 


THE  CAEESS 
From    the   painting    by   Qari  Melchen 


I  hold  you  close:   and  I  could  cry 
Because  you  seem  so  new  and  dear; 
And   such   a  helpless   warder   I 
To  keep  your  candle  burning  clear: 

The  curious  candle  of  your  breath, 
Body 's  and  spirit 's  throbbing  breath. 

Fanny  Stearns  Gifford. 


OBSTETRICAL 
NURSING 

A  TEXT-BOOK  ON  THE  NURSING  CARE  OF 
THE  EXPECTANT  MOTHER,  THE  WOMAN  IN 
LABOR,  THE  YOUNG  MOTHER   AND  HER  BABY 


BY 
CAROLYN  CONANT  VAN  BLARCOM,  R.N, 

Formerly,  assistant   superintendent   and   instructor  in   obstetrical    nursinq 

and  the  care  of  infants  and  children  at  the  johns  hopkins 

hospital      training      school      for      nurses 

Author  of 
"The  Midwife  in  England" 


WITH  200  ILLUSTRATIONS  AND  8  CHARTS 


THE  MACMILLAN  COMPANY 
1926 

All  rights  reserved 


V2> 


.C  .,  //  .r  „    •--    'J^<f 'l^-^      ^A/^^(.t-^lAj^(n/[ 


COPTRIGHT,    1922, 

By   the    MACMILLAN   COMPANY. 


Set  up  and  electrotyped.      Published  May,  1922.     Reprinted 
September,  1922;  January,  May,  1923;  January,  September, 
October,  1924;  April,  September,  1925;  March  ;  October,  1926. 


PRINTED   IN   THE    UNITED   STATES   OF   AMERICA    BY 
THE    BERWICK    &   SMITH   CO. 


THIS   BOOK   IS   DEDICATED 

TO  THE 

SPIRIT   OF   HELPFULNESS 

WHICH  HAS  MADE  ITS  PREPARATION 
POSSIBLE  WITH  THE  HOPE  THAT  IT 
MAY  BE  OF  HELP  TO  THOSE  NURSES 
WHO  TAKE  YOUNG  MOTHERS  AND  BABIES 
INTO  THEIR  CARE. 


(S2SSG1 


PEEFACE 

In  writing  this  book  on  obstetrical  nursing  I  have  been  in- 
fluenced by  certain  steadily  deepening  impressions  which  have 
been  received  in  the  course  of  my  contact  with  maternity  work 
in  this  country,  Canada  and  England  during  the  past  twenty 
years.  It  has  been  borne  in  upon  me,  in  the  first  place,  that 
very  often  there  is  something  akin  to  bewilderment  among  those 
nurses  who  have  been  trained  to  care  for  patients  according 
to  the  teachings  of  one  group  of  obstetricians  and  who  later  find 
themselves  nursing  the  patients  jdJ  other  doctors  who  hold  dif- 
ferent, or  even  opposite  views.  JAnd  not  infrequently  I  have 
found  in  the  nurses  a  degree  of  loyalty  to  their  training  which 
made  them  sceptical,  or  even  intolerant,  of  nursing  methods 
which  differed  from  those  which  they  had  been  taught.  1 

I  have  become  convinced,  therefore,  that  a  book  on  oijstetrical 
nursing  which  would  be  helpful  to  and  widen  the  outlook  of  all 
nurses,  no  matter  where  nor  by  whom  trained,  must  of  necessity 
describe  the  underlying  principles  of  obstetrical  nursing  and 
offer  a  survey  of  the  nursing  methods  which  are  employed  in 
maternity  wards  and  hospitals  of  recognized  excellence  and  in 
the  practice  of  acknowledged  authorities  upon  obstetrics. 

This  is,  I  am  aware,  a  unique  attitude,  fori  the  present  text 
books  on  obstetrics  for  nurses  reflect,  in  each  instance,  the  wishes 
of  one  doctor,  almost  entirely,  or  advocate  the  methods  employed 
in  one  hospital.! /My  experience  in  teaching  obstetrical  nursing 
makes  me  feel  that  a  parallel  description  of  dissimilar  nursing 
procedures  serves  to  broaden  the  nurse's  attitude  toward  her 
work  and  her  grasp  of  the  entire  subject,  both  because  she  be- 
comes aware  of  the  fact  that  methods,  other  than  those  with 
which  she  is  familiar,  are  employed  in  hospitals  of  high  standing 
and  because  she  appreciates  the  fact  that  these  unfamiliar 
methods  may  be  as  efficacious  as  those  in  which  she  has  become 
expert.  ) 


xii  PREFACE 

Accordingly  I  have  devoted  the  better  part  of  the  past  year 
and  a  half  to  a  study  of  the  scope  and  methods  of  the  present 
training  in  maternity  nursing  in  several  hospitals,  in  this  coun- 
try and  Canada,  in  which  the  obstetrical  work  is  of  a  conspicu- 
ously high  character,  and  have  presented  a  composite  of  this 
teaching  in  the  succeeding  pages. 

But  that  there  might  not  be  apparent  inconsistencies  in  the 
different  methods  of  maternity  care  described,  I  have  given  an 
explanation  of  the  purposes  and  general  principles  of  the  care, 
including  nursing,  which  the  nurse  is  likely  to  find  is  given  to 
all  obstetrical  patients,  the  country  over. 

For  the  sake  of  simplicity  and  clarity  I  have  divided  the 
book  into  seven  parts,  following  an  introduction  Avhich  describes 
the  requisites  and  opportunities  of  obstetrical  nursing  and  the 
importance  of  the  nurse's  own  attitude  toward  her  work  and  her 
patient.  The  first  two  parts,  dealing  with  the  normal  anatomy 
and  physiology  of  the  female  generative  tract  and  the  develop- 
ment of  the  fetus,  are  designed  to  supply  the  nurse  with  enough 
technical  information  to  make  her  ministrations  intelligent  and 
effective.  In  this  respect,  I  have  doubtless  given  less  than  some 
nurses  will  wish  and  possibly  more  than  others  will  think  neces- 
sary, but  I  have  given  about  the  average  amount  of  instruction 
that  is  found  satisfactory  in  the  training  schools  of  high  stand- 
ing. Four  of  the  succeeding  parts  are  devoted  respectively  to  a 
description  of  the  nurse's  duties  during  pregnancy,  labor,  the 
puerperium  and  early  infancy.  In  each  of  these  I  have  explained, 
first,  the  normal  physiological  processes  which  take  place ;  then, 
the  nurse's  duties  under  average  conditions  and  finally,  her 
responsibilities  in  the  event  of  complications  or  abnormalities.  A 
separate  part  is  devoted  to  a  description  of  the  organized  care 
and  instruction  of  the  maternity  patient,  by  public  health  nurses, 
both  before  and  after  delivery,  which  have  proved  to  be  satis- 
factory. 

While  describing  various  hospital  procedures,  I  have  deemed 
it  of  practical  importance  to  explain,  in  each  instance,  how 
similar  results  might  be  obtained,  with  improvised  appliances,  in 
a  patient's  home  whether  in  a  city  or  a  rural  community.    In 


PREFACE  xiii 

short,  I  have  endeavored  to  make  clear  the  essentials  of  obstet- 
rical nursing  without  regard  to  the  status  or  location  of  the 
patient. 

Since  the  patient's  state  of  nutrition  and  her  frame  of  mind 
are  of  vital  importance  throughout  pregnancy,  labor  and  the 
puerperium,  I  have  not  only  dwelt  upon  them  in  all  descriptions 
of  the  nurse's  duties  during  these  periods  but  have  devoted  an 
entire  chapter  to  a  simple  explanation  of  the  principles  of  each 
of  these  two  important  subjects. 

My  varied  contact  with  obstetrical  nurses  has  convinced  me 
that  those  nurses  who  appreciate  the  never  ending  wonder  and 
beauty  of  this  miracle  of  the  beginning  of  a  new  life,  derive 
peculiar  satisfaction  from  the  care  of  the  maternity  patient. 
At  the  same  time,  in  many  hospitals,  even  where  the  patients  are 
given  the  most  conscientious  care,  the  nurses  are  often  so  nearly 
overwhelmed  by  the  long,  irregular  hours  and  the  insistent  de- 
mands of  routine  duties,  that  they  do  not  grasp  the  significance 
of  the  event  in  which  they  are  participants.  Accordingly,  I 
have  made  a  sustained  effort  throughout  the  following  pages 
to  give  the  young  nurse  something  of  a  feeling  of  reverence  for 
this  great  mystery  of  birth. 

In  the  course  of  my  survey  of  the  present  training  in  ob- 
stetrical nursing,  I  have  met  the  warmest  generosity  on  the  part 
of  the  obstetrical  and  nursing  staffs  in  all  of  the  hospitals  which 
I  have  visited.  Accordingly,  I  find  it  very  difficult  to  find  ade- 
quate expression  for  my  sense  of  gratitude  to  the  doctors  and 
nurses  of  the  Montreal  Maternity  Hospital;  the  Burnside  Ob- 
stetrical Department  of  the  Toronto  General  Hospital;  The 
Hospital  of  the  University  of  Pennsylvania ;  Bellevue  Hospital ; 
The  Long  Island  College  Hospital;  The  Brooklyn  Hospital; 
The  Cleveland  Maternity  Hospital  and  to  Dr.  J.  Whitridge 
Williams  and  Miss  Elsie  Lawler  for  making  available  the  entire 
resources  of  the  wards,  clinics,  laboratories  and  class  and  lecture 
rooms  at  Johns  Hopkins  Hospital, 

I  wish  to  offer  an  expression  of  deepest  possible  appreciation 
to  Dr.  John  W.  Harris  for  the  generosity  with  which  he  has 
given  of  his  time,  thought  and  wide  experience  in  an  effort  to 


xiv  PREFACE 

provide  accurate  and  practical  information,  and  to  set  a  high 
standard  of  work  and  ideals  for  those  nurses  who  would  be 
influenced  by  this  book.  Having  taught  and  lectured  to  nurses, 
as  well  as  medical  students,  for  years,  Dr.  Harris  is  in  a  posi- 
tion to  give  counsel  and  criticism  of  peculiar  value  to  a  book 
on  obstetrical  nursing  and  he  has  given  these  throughout  the 
entire  preparation  of  this  book. 

Because  of  their  concern  with  any  effort  to  better  the  state 
of  mothers  and  babies,  I  have  been  given  suggestions,  assistance 
and  inspiration  with  the  most  selfless  generosity  by  The  Rev- 
erend Father  John  J.  Burke ;  Dr.  J.  Clifton  Edgar ;  Dr.  Frederic 
W.  Rice;  Dr.  J.  P.  Crozer  Griffith;  Dr.  Caroline  F.  J.  Rickards; 
Dr.  Esther  Loring  Richards;  Dr.  E.  V.  McCollum;  Miss  Nina 
Simmonds.  and  Dr.  John  R.  Eraser.  Among  the  many  nurses 
with  whom  I  have  conferred,  I  have  met  a  characteristic  spirit 
of  helpfulness  which  has  expressed  itself  in  their  eager  readi- 
ness to  pass  on  to  other  nurses  the  beneflts  of  their  own  training 
and  experience.  Those  to  whom  I  am  especially  indebted,  for 
aid  and  suggestions,  are  Miss  Calvin  MacDonald;  Mrs.  Bessie 
Amerman  Haasis ;  Miss  Robina  Stewart ;  Miss  Caroline  V.  Bar- 
rett; Miss  Katherine  de  Long;  Miss  Jean  Gunn;  Miss  Mary  E. 
Robinson ;  Miss  Sara  Cooper ;  Miss  Laura  F.  Keesey ;  Miss  Chelly 
Wasserberg;  Miss  Kate  Madden;  Mrs.  Minnie  S.  Brown;  Miss 
Anne  Stevens;  Miss  Madge  Allison  and  Miss  Katherine  Tucker. 

To  Mrs.  Elizabeth  Porter  Wyckoff  I  am  under  heavy  obliga- 
tion for  most  discriminating  editorial  assistance  and  for  her  far- 
sighted  criticisms  toward  increasing  the  clarity  of  the  text.  And 
I  feel  sure  that  the  tender  little  poem  on  the  miracle  of  mother- 
hood, which  Mrs.  Elizabeth  Newport  Hepburn  wrote  expressly 
for  this  book,  will  be  as  warmly  appreciated  by  my  readers  as 
it  is  by  me. 

I  wish  to  express  my  deep  gratitude  to  Mr.  Max  Brodel  for 
his  invaluable  counsel  and  guidance  in  planning  and  assembling 
the  illustrations  to  elucidate  the  text.  And  I  am  very  grateful  to 
Mr,  Gari  Melchers  for  the  spirit  which  I  believe  is  infused  into 
this  book  through  the  reproduction  of  two  of  his  lovely 
paintings  of  a  mother  and  baby,  and  to  Mr.  Russell  Drake  for 


PREFACE  XV 

his  valuable  drawings.  I  wish  further  to  thank  Mr.  J.  Norris 
Myers,  of  The  Maemillan  Company,  for  unfailing  courtesy  and 
helpfulness  in  facilitating  all  matters  relating  to  the  publication 
of  this  book. 

For  statistical  information  I  am  indebted  to  Dr.  Louis  I. 
Dublin  and  for  authority  in  offering  the  scientific  background 
of  the  teaching  I  have  drawn  from  "The  Practice  of  Obstetrics" 
by  J.  Clifton  Edgar;  "Obstetrics"  by  J.  Whitridge  Williams; 
"The  Diseases  of  Infants  and  Children"  by  J.  P.  Crozer  Grif- 
fith and  "The  Prospective  Mother"  by  J.  Morris  Slemons. 

Carolyn  Conant  Van  Blarcom. 
New  York  City,  149  East  40th  Street 


TABLE  OF  CONTENTS 

fAQZ 

Preface     ......         :a 

Intewduction 3 

PART  I. 
ANATOMY  AND  PHYSIOLOGY 

CHAPTER 

I.    Anatomy  of  thk  Female  Pelvis  and  Geneeattve  Organs      19 
II.    Physiology        45 


PAET  n. 

THE  DEVELOPMENT  OF  THE  BABY 

III.  Development  of  the  Ovum,  Embryo,  Fetus,  Placenta, 

Cord  and  Membranes 61 

IV.  Physiology  op  the  Fetus 84 

V.    Signs,  Symptoms,  and  Physiology  of  Pregnancy  ...      S3 

PART  III. 

THE  EXPECTANT  MOTHER 

VI.    Prenatal   Care Ill 

VII.    Mental  Hygiene  of  the  Expectant  Mother    ....     145 

VIII.     Preparation    op   Room,    Dressings,    and    Equipment   for 

Home    Delivery 155 

IX.    Complications  and  Accidents  op  Pregnancy  ....     164 

PART  TV. 
THE  BIRTH  OF  THE  BABY 

X.    Presentation  and  Position  of  the  Fetus 217 

XI.    Symptoms,  Course,  and  Mechanism  op  Normal  Labor   .  232 

XII.    Nurse's   Duties   During   Labor 243 

XIII.    Obstetrical   Operations   and   Complicated   Labors    .     .  295 


xviii  TABLE  OF  CONTENTS 

CHAPTEB  VASI 

PART    V. 

THE  YOUNG  MOTHER 

XIV.    Physiology  of  the  Puerperium 317 

XV.    Nursing  Care  During  the  Normal  Puerperium    .     .     .  323 

XVI.    The   Nursing   Mother 357 

XVII.     Nutrition  of  the  Mother  and  Her  Baby 368 

XVIII.    Complications  of  the  Puerperium 391 

PART  VI. 
THE  MATERNITY  PATIENT  IN  THE  COMMUNITY 

XIX.     Organized  Prenatal  Work 405 

XX,    Care  of  the  Mother  and  Baby  by  Visiting  Nurses     .     .407 

PART  VII. 
THE  CARE  OfF  THE  BABY 

XXI.    Characteristics  and  Development  of  the  Average  New- 
born Baby 451 

XXII.    Nursing  Care  of  the  Average  New-born  Baby  ....     461 

XXIII.  Common  Disorders  and  Abnormalities  of  Early  Infancy    sig 

XXIV.  A  Final  Word 544 


LIST  OF  ILLUSTRATIONS   AND  CHARTS 

ILLUSTRATIONS 
Anatomy  and  Physiologt. 

FIO.  PAGE 

1  a.    Normal  female   pelvis 21 

b.    Normal  male  pelvis 21 

2.  Diagram  of  pelvic  inlet  seen  from  above 22 

3.  Diagram   of  pelvic   outlet  seen   from   below 23 

4.  Sagittal   section   of  the   pelvis 24 

5.  Twa  types  of  pelvimeters 25 

6.  Diagram  showing  method  of  measuring  distance  between  crests, 

spines  and  trochanters 26 

7.  Diagram  showing  method  of  measuring  Baudelocque  's  diameter  27 

8.  Diagram  showing  method  of  estimating  true  conjugate  ...  28 

9.  Diagram  showing  method  of  measuring  intertuberous  diameter  .  29 

10.  Anterior  view  of  external  and  internal  female  generative  organs  31 

11.  Diagrams  of  sections  of  virgin  and  multiparous  uteri  ...  32 

12.  Sagittal  section  of  female  generative  tract 35 

13.  Diagram   of  external   female   genitalia 39 

14.  Sagittal  section  of  breast 42 

15.  Front  view  of  breast 43 

16.  Diagram  of  human  ovum 47 

Development  of  the  Baby 

17.  Diagram    of   human    spermatozoa 61 

18.  Diagram  of  segmenting  rabbit's  ovum 65 

19.  Ovum  about  13  days  old  embedded  in  the  decidua       ...  66 

20.  Diagram  of  developing  fetus,  cord,  membranes  and  placenta  in 

utero 69 

21.  Diagram  of  structure  of  placenta 71 

22.  Photograph  of  placental  vessels 72 

23.  Maternal  surface   of   the  placenta 74 

24.  Fetal  surface  of  the  placenta 75 

25.  Embryo  about  5.5  cm.  long  in  amniotic  sac 77 

26.  Outlines  of  fetus  at   different  stages 78 

27.  Full  term  fetus  in  utero 81 


XX 


LIST  OF  ILLUSTRATIONS  AND  CHARTS 


PIG. 

28. 


PAGE 

85 


Diagram  of  fetal  circulation 

29.  Diagram  of  circulation   after  birth 87 

30.  Side  and  top  view  of  fetal  skull       .......      90 


The  Expectant  Mother. 

31.  Height  of  fundus  at  different  stages  of  pregnancy     ...  94 

32.  Contour   of   abdomen   at  ninth   month 95 

33.  Contour  of  abdomen  at  tenth  month 95 

34.  Front  view  of  home-made  abdominal  binder 123 

35.  Side    view    of    same 123 

36.  Back   view    of    same 123 

37.  Abdominal  binder   used   in   above 124 

38.  Front  view  of   home-made  stocking  supporters      ....  124 

39.  Back   view   of    same 124 

40.  Patient  in  right-angled  position  to  relieve  varicose  veins   .        .  138 

41.  Elevated   Sims    position 139 

42.  Gloves,  ready  for  dry  sterilization 160 

43.  Delivery  pad  of  newspapers  and  old  muslin 161 

44.  Diagram  of  centrally  implanted  placenta  prsevia   ....  174 

45.  Partial   placenta    praevia 175 

46.  Diagram  of   marginal   placenta  prsevia 176 

47.  Champetier  de  Eibes'  bag  inserted  in  uterus 177 

48.  Patient  in  hot  pack  given  with  dry  blankets 197 

49.  Method  of  giving  infusion 202 


The  Birth  of  the  Baby. 

50.  Attitude    of    fetus   in   uterus    at    term 

51.  Illustration  from  first  text-book  on  obstetrics 

52.  Attitude   of  fetus  in  breach  presentation 

53.  Attitude  of  fetus  in  vertex  presentation 

54.  Diagram  of  six  positions  in  a  vertex  presentation 

55.  Diagram  of  six  positions  in  a  face  presentation 

56.  Diagram  of  six  positions  in  a  breech  presentation 

57.  First  maneuver  in  abdominal  palpation 

58.  Second  maneuver   in   abdominal  palpation 

59.  Third  maneuver  in  abdominal  palpation  . 

60.  Fourth   maneuver  in  abdominal  palpation 

61.  Diagrams  showing  positions  of  nurse 's  hands  in  four 

of  abdominal  palpation       .... 

62.  Ascertaining  position  of  fetus  by  rectal  examination 


maneuvers 


217 
218 
219 
22C 
222 
223 
223 
225 
226 
227 
228 

229 
236 


LIST  OF  ILLUSTRATIONS  AND  CHARTS 


XXI 


rra. 

63-64-65-66.     Diagrams   showing   stages   of    dilatation    and  oblitera- 
tion of  cervix    

67.  Characteristic  position  of  patient  during  first  stage  pains     . 

68.  Diagram  indicating  rotation  and  pivoting  of  head  during  birth 
69. 
70. 
71. 


Anterior  shoulder  being  slipped  from  under  symphysis 

Birth   of   posterior    shoulder 

Diagrams    of    Duncan    and    Schultze    mechanisms    of    placentaf 
separation 

72.  Section  showing  thinness  of  uterine  wall  before  birth  of  fetus 

73.  Section  showing  thickness  of  uterine  wall  immediately  after  labor 

74.  Preparing  patient  for  vaginal  examination  or  delivery 

75.  Patient   draped  for   vaginal   examination 

76.  Wrong  and  right  methods  of  boiling  gloves 

77.  Powdering  hands  before  putting  on  dry  gloves 

78.  Successive  steps  in  proper  method  of  putting  on  gloves 

79.  Bed  and  simple  equipment  ready  for  normal  delivery     . 

80.  Instruments  shown  in  Fig.  79     ...        . 

81.  Old  prints  showing  early  methods  of  delivery 

82.  Patient  draped  with  sterile  dressings  for  delivery 

83.  Patient  pulling  on  straps  while  bearing  down  during  second  stage 

84.  Palpating  baby's  head  through  perineum 

85.  Baby's  head   appearing  at  vulva 

86.  Head    farther    advanced      .... 

87.  Holding  back  head  at  the  height  of  a  pain 

88.  External  rotation  following  birth  of  head 

89.  Wiping  mucus  from  baby's  mouth     . 

90.  Stroking  baby's  back  to  stimulate  respirations 

91.  Two  clamps  on  cord  after  pulsation  has  ceased 

92.  Wrong  and  right  method  in  tying  knot  in  cord  ligature 

93.  Stimulating  baby  's  respirations 

94-95.  Stimulating  baby's  respirations 275, 

96-97.  Eesuscitating  baby  by  holding  under  warm  water       .        .    277, 

98.  Eesuscitation  by  means  of   direct   insufflation 

99.  Delivery  of  the  placenta 

100.  Twisting  membranes   while   withdrawing  placenta 

101.  Massaging  fundus  through  abdominal  wall 

102.  Showing  prolapsed  cord  between  head  and  pelvic  brim 

103.  Giving   chloroform  for   obstetrical   anaesthesia 
104-105.  Giving  ether  for  obstetrical  anaesthesia       ....     289, 
106.     Giving  ether  for  complete  anaesthesia 


PAGE 

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272 
274 
276 
278 
279 
280 
281 
282 
285 
287 
290 
293 


xxii  LIST  OF  ILLUSTRATIONS  AND  CHARTS 

FIO.  PAGB 

107.  a.   Tarnier  forceps,     b.  Simpson  forceps 301 

108.  Patient  in  position  and  draped  for  forceps  operation  .        .       .  302 

109.  Forceps   sheet  used  in   Fig.   108 303 

110.  Two  types  of  leggings  for  obstetrical  use 304 

111.  Eubber   bougie 311 

112.  Champetier  de  Eibes'  bag 311 

113.  Voorhees'    bag 312 

114.  Bag  held  in  forceps  for  introduction  into  uterus        .        .        .  312 

115.  Syringe  for  filling  above  bags  after  insertion      ....  312 

The  Young  Mother. 

116.  Height  of  fundus  on  each  of  first  ten  days  after  delivery       .  327 

117.  Patient    draped    for    postpartum    dressing 336 

118.  Equipment  in  rack  used  in  Fig.   117 337 

119.  Method  of  covering  nipples  with  sterile  gauze       ....  339 

120.  Baby  nursing  through  a  nipple  shield 341 

121.  Nipple   shield   used   in   Fig.    120 342 

122.  Supporting  heavy  breasts  by  means  of  folded  towels    .        .        .  343 

123.  Ice  caps  applied  to  engorged  breasts 344 

124.  Y  binder  before   application 345 

125.  Y    binder    applied 346 

126.  The  same   seen  from  the  other  side 347 

127.  Indian    binder        . 347 

128.  Method  of  stripping 348 

129.  130,   131,  132,   133,   134,   135.     Bed  exercises  taken   during  the 

puerperium 350  to  353 

136.  Knee-chest    position 354 

137.  Exercising  by   walking   on   all   fours 354 

138.  Position  of  mother  and  baby  for  nursing  in  bed     ....  359 

139.  The  Nursing  Mother   (from  a  painting  by  Gari  Melchers)        .  361 

140.  Baby  partially  blind  as  a  result  of  a  faulty  diet       .        .        .  378 

141.  Eachitic  and  normal  babies  of  the  same  age        ....  381 

142.  Chest  walls  of  normal  and  rachitic  rats  of  the  same  age       .        .  383 

143.  Interior  of  specimens  in  Fig.  142 384 

The  Maternity  Patient  in  the  Communitt. 

144.  Baby's  bed  improvised  from  a  market  basket       ....  415 

145.  Layette  recommended  to  expectant  mothers  by  Maternity  Centre 

Association *^6 

146.  Breast  tray  recommended  to   expectant  mothers  by   Maternity 

Centre  Association *17 


LIST  OF  ILLUSTRATIONS  AND  CHARTS       xxiii 

FIG.  PAGE 

147.  Baby's  toilet  tray  recommended  to  expectant  mothers  by  Ma- 

ternity Centre  Association  .        .        .        .        .        .        .        .  417 

The  Baby. 

148.  Diagram  of  first  teeth 456 

149.  Umbilical  cord  immediately   after   birth 457 

150.  The   same   four  days   later 457 

151.  Umbilicus  immediately  after  separation  of  cord     ....  458 

152.  Well    healed    umbilicus 458 

153.  Nursery  at  Mahattan  Maternity  Hospital 465 

154.  Bathing    the    baby 467 

155.  Preparation  for  circumcision 468 

156.  Baby  draped  with  sterile  sheet,  in  above 469 

157.  Cord  dressed  with   dry   sterile   gauze 470 

158.  Abdominal  binder  applied  over  cord  dressing       ....  471 

159.  Satisfactory  baby  clothes 473 

160.  Diagonally  folded   diaper  applied 474 

161.  Longitudinally  folded  diaper  applied 474 

162.  Sutton  poncho  to  protect  baby  for  outdoor  sleeping   .        .        .  479 

163.  Training  the  baby  to  use  a  chamber 481 

164.  Stiff  cuffs  to  prevent  thumb   sucking 483 

165.  Hammer  cap   to  prevent  ruminating 484 

166.  Ruminating  cap  applied 485 

167.  Proper  method  of  carrying  baby 487 

168.  Preparing   the   baby's   milk 493 

169.  Giving  the  baby  his  bottle 496 

170.  Holding  baby  upright  after  feeding 497 

171.  Dr.  Griffith's  table  of  fat  percentages 500 

172.  Reverse  side  of  above  card 501 

173.  Baby  in  a  basket  ready  to  travel 507 

174.  Quilted  robe  with  hood  for  the  premature  baby     ....  509 

175.  Premature  baby  in  lined  basket,  being  fed  with  Boston  feeder  510 

176.  Bed  for  premature  baby  improvised  from  small  clothes  basket  511 

177.  Putting  the  baby  in  a  wet  pack 521 

178.  Baby  in  wet  pack 522 

179.  Diagrams  showing  successive  steps  in  giving  the  baby  a  pack  522 

180.  Baby  wrapped  in  blanket  preparatory  to  gavage       .        .        .  523 

181.  Gavage 524 

182.  Obtaining  a  fresh  specimen  of  urine  from  the  baby     .        .        .  526 

183.  Obtaining  a  24-hour  specimen  of  urine  from  the  baby     .        .  527 


xxiv       LIST  OF  ILLUSTRATIONS  AND  CHARTS 

riG-  PAGE 

184.  Band  to  hold  baby's  legs  while  obtaining  specimens  of  urine     .  527 

185.  Belt  used  to  hold  tube  for  specimen 528 

186.  Giving   the   baby   an   enema 530 

187.  Irrigating  the  eye  with  a  blunt  nozzle 536 

188.  Method  of  holding  baby  for  treating  gonorrhoeal  ophthalmia     .  537 

CHAETS. 

NO. 

1.  Showing  drop   in   blood   pressure   and   albumen,   after   delivery, 

in  eclampsia 204 

2.  Showing  persistence  of  high  blood  pressure  and  albumen  in  the 

urine,  after  delivery,  in  nephritic  toxaemia  with  convulsions  "06 

3.  Showing  temperature  curve  in  streptococcus  infection   .        .        .  397 

4.  Showing  temperature  curve  in  gonorrhoeal  infection       .        .        .  398 

5.  Showing  normal  weekly  gain  in  weight  during  first  year  of  life  454 

6.  Showing  normal  daily  gain  in  weight  during  first  two  weeks     .  520 

7.  Showing  loss  of  weight  in  inanition  fever  contrasted  with  No.  6  520 

8.  Showing  rise  in  temperature  in  inanition  fever       ....  520 


OBSTETRICAL  NURSING 


''Can  there  be  any  higher  work  than  this? 
Can  any  woman  wish  for  a  more  womanly  work?" 

Florence  Nightingale 


INTRODUCTION 

The  avowed  purpose  of  care  given  to  the  maternity  patient 
to-day  is  to  minimize  the  discomforts  and  perils  of  her  preg- 
nancy, labor,  and  the  pnerperium,  and  so  safeguard  her  and  her 
baby  that  both  will  emerge  from  the  lying-in  period  in  a  satis- 
factory condition  and  with  a  bright  prospect  of  having  perma- 
nently good  health. 

The  striking  difference  between  obstetrics  as  practiced  to-day, 
and  that  of  former  times,  is  that  it  now  lays  as  much  stress  upon 
the  future  health  of  the  mother  and  baby  as  it  does  upon  their 
immediate  safety. 

Happily,  the  present-day  obstetrician,  who  assumes  the  care 
of  an  expectant  mother,  does  so  with  confidence  and  optimism 
because  of  the  available  knowledge  upon  which  he  may  draw 
for  her  benefit.  Progress  in  the  various  branches  of  medicine 
and  nursing  is  steadily  pointing  the  way  toAvard  greater  and 
more  effective  safeguards  for  the  maternity  patient  and  her 
baby. 

The  value  of  these  safeguards  is  attested  to  by  the  satisfactory- 
results  of  the  care  which  is  given  to  the  patients  in  well  con- 
ducted hospitals  or  in  their  homes  by  careful  physicians;  by 
various  out-patient  departments  and  nursing  organizations  to 
patients  within  their  reach.  These  results  are  in  the  form  of  a 
large  proportion  of  mothers  and  babies  who  are  well  and  continue 
to  be  well. 

That  is  one  view  of  the  matter.  Looking  at  it  from  another 
aspect,  we  discover  that  more  than  seven  women  still  lose  their 
lives  for  each  1,000  births  that  occur  in  this  country,  the  actual 
number  varying  in  different  localities.  Childbirth  is  still  sec- 
ond to  tuberculosis  as  a  cause  of  death  among  women  between 
fifteen  and  forty-five  years  of  age,  and  in  spite  of  the  proved 
value  of  care  in  making  maternity  a  safe  adventure,  the  larger 

3 


4  INTRODUCTION 

proportion  of  these  women  die  from  infection  or  toxaemia  which 
are  almost  entirely  preventable. 

The  incredible  fact  in  this  connection  is  that,  while  there  has 
been  a  decline  in  the  deaths  from  such  other  controllable  condi- 
tions as  typhoid  fever  and  some  of  the  infectious  diseases  of 
childhood,  there  has  been  an  actual  increase  in  deaths  from 
preventable  causes  associated  with  child-bearing. 

Dr.  Dublin  estimates  that  throughout  the  United  States  as  a 
whole,  during  1920,  the  total  number  of  deaths  due  to  child- 
birth was  about  20,000. 

In  addition  to  the  high  death  rate  among  mothers  the  mor- 
tality among  babies  is  even  greater.  Dr.  Dublin  estimates  that 
out  of  every  1,000  babies  born  during  1920,  about  85  died  before 
they  were  a  year  old,  or  about  200,000  in  the  course  of  the  year, 
and  that  the  large  majority  of  these  died  from  congenital  causes, 
from  infection  or  nutritional  disturbances.  Another  100,000 
babies  perish,  yearly,  through  still  births.  As  all  of  these  con- 
ditions are  preventable  to  a  greater  or  lesser  degree,  we  have  to 
acknowledge  that  many  babies  die  whom  we  know  how  to  save. 
There  is  sound  reason,  therefore,  for  the  belief  that  proper 
care  would  save  the  lives  of  about  two-thirds  of  the  mothers  and 
half  of  the  babies  who  now  die  and  half  of  the  babies  who  are 
born  dead. 

And  let  it  be  remembered  that  conditions  which  destroy  life, 
also  destroy  or  greatly  impair  health  and  resistance  to  disease. 
Although  we  may  count  the  number  of  mothers  and  babies  who 
fail  to  survive  the  too  severe  test  to  which  they  are  put  during 
crucial  periods  in  the  lives  of  both,  we  cannot  count,  nor  even 
approximately  estimate,  the  number  of  those  who  escape  death 
only  to  be  imprisoned  in  frail,  deformed,  or  diseased  bodies. 
Therein  lies  much  of  the  tragedy  which  follows  in  the  wake  of 
neglect — the  lifelong  handicaps,  suffering,  and  inefficiency  that 
need  not  have  been. 

This  lack  of  care  is  not  due  to  limitations  in  medical  knowl- 
edge, for  the  efficacy  of  known  methods  is  being  constantly 
demonstrated.  And  our  instant  and  generous  response,  the 
country  over,  to  appeals  for  help  in  relieving  various  forms  of 
need  and  disaster  does  not  suggest  a  national  cold-bloodedness, 


INTRODUCTION  5 

or  even  indifference,  to  needless  suffering.  But  still  a  legion  of 
mothers  and  babies  die  each  year  from  lack  of  care,  and  almost 
at  our  very  thresholds. 

Perhaps  the  root  of  the  difficulty  lies  in  the  fact  that  child- 
birth, as  well  as  the  attendant  suffering  and  death,  are  so  fa- 
miliar that  they  are  regarded  as  being  normal  incidents  in  the 
ordinary  course  of  affairs. 

One  of  the  most  dramatic  of  all  human  events,  the  birth  of  a 
new  being,  is  accepted  casually,  almost  without  concern,  because 
it  is  so  frequent — so  commonplace. 

Moreover,  we  are  all  accustomed  to  hearing  stressed  the  fact 
that  child-bearing  is  not  a  disease,  but  is  a  normal  physiological 
function. 

Not  so  generally,  however,  do  we  hear  emphasis  made  upon 
the  equally  important  facts  that  there  is  extreme  danger  of  infec- 
tion while  these  physiological  functions  are  in  progress,  and 
that  they  subject  the  entire  organism  to  such  a  strain  that  there 
results  a  dangerously  narrow  margin  between  health  and  disease. 

Accordingly,  too  much  is  expected,  or  taken  for  granted, 
from  the  provisions  which  Nature  has  made  to  promote  these 
functions,  and  not  enough  assistance  is  given  to  protect  the 
mother,  while  they  are  in  course,  or  to  help  the  immature  baby 
in  adjusting  himself  to  the  greatest  change  which  he  makes  dur- 
ing the  entire  span  of  his  existence. 

When  the  time  comes,  and  it  seems  to  be  approaching,  that 
pregnancy,  labor,  the  puerperium  and  infancy  are  regarded  as 
crucial  periods  in  the  life  history,  demanding  all  the  preventives 
and  safeguards  that  all  branches  of  medicine  and  nursing  can 
offer,  these  periods  will  cease  to  be  so  enormously  destructive  of 
life  and  health. 

We  cannot  build  a  strong  race  with  sickly  and  maimed 
mothers  and  babies,  and  we  can  scarcely  have  other  than  sickly 
and  maimed  mothers  and  babies  without  care. 

Apparently,  then,  our  national  health  is  in  a  large  measure 
dependent  upon  good  obstetrics  and  good  obstetrics  includes 
good  nursing. 

Good  nursing  implies  more  than  the  giving  of  bed  baths  and 
medicines,  boiling  instruments  and  serving  meals.     It  is  more 


6  INTRODUCTION 

than  going  on  duty  at  a  certain  time,  carrying  out  orders  for  a 
certain  number  of  hours  and  going  off  duty  again.  It  implies 
care  and  consideration  of  the  patient  as  a  human  being  and 
a  determination  to  nurse  her  well  and  happily,  no  matter 
what  this  demands. 

In  carrying  on  her  work,  the  maternity  nurse  may  be  called 
upon  to  aid  in  prenatal  supervision  and  instruction;  to  pre- 
pare for  and  assist  with  a  delivery,  or  to  give  either  exclusive 
or  visiting  nursing  care  to  a  young  mother  and  her  baby.  These 
patients  may  be  in  a  hospital  or  at  home  and  the  home  may 
be  of  any  kind  from  a  palace  to  a  hut  or  a  tenement.  The 
patients  may  be  in  a  city,  a  small  town,  or  a  rural  community, 
and  in  the  care  of  doctors  whose  methods  vary  widely. 

But  in  spite  of  the  diversity  of  conditions  and  the  fact 
that  no  two  will  be  quite  alike,  the  general  need  of  all  of 
these  patients  will  be  the  same. 

Their  need  is  care,  which  includes  cleanliness  in  order  to 
prevent  infection ;  suitable  food ;  fresh  air  and  exercise ;  regular 
and  sufficient  rest  and  sleep ;  an  equable  body  temperature ; 
early  treatment  of  complications  and  correction  of  physical  de- 
fects. In  short,  each  patient  needs  to  be  watched;  needs  clean 
care  and  to  practice  the  approved  principles  of  personal  hygiene 
from  the  beginning  of  pregnancy.  This  without  regard  to 
race,  color,  creed,  occupation,  status,  or  location.  It  means 
all  maternity  patients  and  their  babies  the  country  over. 

There  was  a  time  when  the  obstetrician  first  saw  his  patient 
in  labor  or  shortly  beforehand,  and  when  the  care  of  the  baby 
began  at  birth  or  soon  afterward. 

We  know  what  this  tardy  attention  Las  cost  in  human  lives 
and  suffering. 

We  know,  too,  that  among  the  mothers,  abortion,  miscar- 
riages, toxaemias,  difficult  or  impossible  labors  may  be  largely 
prevented  through  prenatal  care;  while  among  babies,  the 
enormously  high  death  rate,  during  the  first  month  of  life 
from  causes  which  begin  to  operate  before  birth,  convinces  us 
that  we  must  begin  to  take  care  of  the  baby  nine  months  before 
he  is  born,  if  he  is  to  have  the  greatest  benefits  of  present 
available  knowledge.  Such  early  care  reduces  still  births  and 
injury  during  labor;  it  reduces  premature  births,  which  is  im- 


INTRODUCTION  7 

portant,  because  the  nearer  tlie  baby  goes  to  term  the  better 
his  chance  of  survival  and  of  good  liealth,  and  prenatal  care 
also  increases  the  prospects  of  satisfactory  breast  feeding. 

Although  we  knoAV  that  the  ideal  is  to  have  all  maternity 
patients  supervised  and  instructed  entirely  by  a  physician 
from  the  beginning  of  pregnancy  and  then  delivered  in  a  well 
conducted  hospital,  it  is  scarcely  probable  that  this  ideal  will 
ever  be  realized.  There  will  always  be  patients  who  cannot 
afford  to  employ  a  doctor  for  so  long  a  period ;  there  will  always 
be  communities  in  which  hospital  provisions  do  not  exist  or  are 
inadequate.  There  will  alwaj's  be  expectant  mothers  whom  it 
would  be  unwise  to  remove  from  home,  excepting  under  press- 
ing conditions,  because  of  the  influence  exerted  by  their  mere 
presence  in  keeping  the  family  group  intact.  And  so  on, 
through  a  number  of  deterring  conditions  which  Avill  probably 
never  cease  to  exist,  and  which  will  keep  the  patient  at  home. 

Since  patients  who  are  supervised  during  pregnancy  and 
delivered  in  hospitals  usually  recover,  the  high  rate  of  death 
and  injury,  in  this  country,  is  to  be  found  among  women  who 
are  unsupervised  before  labor  and  subsequently  delivered  at 
home.  Accordingly,  if  this  widespread  injury  is  to  be  reduced, 
the  essentials  of  the  care  which  is  found  to  be  efficacious  must 
be  made  available  for  all  patients  throughout  the  length  and 
breadth  of  the  land. 

Prenatal  care,  clean  deliveries,  and  intelligent  motherhood 
will  go  far  toward  solving  the  problem  of  a  high  maternal  and 
infant  death  rate,  and  these  require  not  widespread  care,  alone, 
but  widespread  teaching  as  well — impressing  upon  women  and 
their  families  the  importance  of  care  and  precautions  in  con- 
nection with  childbirth.  Important  as  it  is  for  men  to  study 
and  inform  themselves  in  regard  to  the  problems  of  finance 
and  cattle  raising,  for  example,  it  is  still  more  important  for 
both  men  and  women  to  .study  and  a])pi'eciate  the  i)roblcms  of 
expectant  and  actual  motherhood. 

It  is  in  this  teaching  that  the  nurse  may  be  immeasurably 
helpful,  in  fact  is  indispensable,  for  the  carrying  of  approved 
care  into  the  home  and  the  general  teaching  of  personal  hygiene 
are  inextricably  bound  up  with  nursing. 

M 


8  INTRODUCTION 

The  details  of  the  care  and  teaching  of  patients  are,  of 
course,  specified  by  a  doctor  or  a  medical  board,  but  the  effec- 
tiveness of  the  planning,  whether  for  one  or  several  patients,  is 
very  largely  dependent  upon  the  nurse's  intelligence,  interest 
and  conscientiousness,  and  her  ability  to  teach. 

This  is  borne  out  by  the  almost  uniform  recommendations, 
made  by  official  bodies,  for  provisions  looking  toward  the  re- 
duction of  maternal  and  infant  deaths  including  as  they  do  the 
following : 

1.  The  employment  of  public  health  nurses.  (To  give  home 
care  or  instruction  or  both.) 

2.  The  establishment  of  prenatal  clinics  and  baby  health  cen- 
ters. (In  both  of  these  the  nurse  aids  in  supervising  and 
teaching  the  mother  how  to  take  care  of  herself  and  her 
baby.) 

3.  Trained  attendance  during  labor.  (The  nurse  aids  greatly 
in  preparing  for  and  assisting  with  clean  deliveries.) 

4.  Improved  and  increased  hospital  facilities.  (There  cannot 
be  good  hospital  work  without  good  nursing.) 

5.  Prompt  and  accurate  registration  of  births.  (Here,  too, 
the  nurse  may  be  helpful  by  always  making  sure  that  the 
birth  has  been  reported.) 

Here  is  no  light  task  nor  mean  privilege  which  is  set  before 
the  nurse  and  in  order  to  meet  them  fitly  she  must  be  prepared. 
The  indispensable  requisites  for  nursing  and  teaching  the  ma- 
ternity patient,  whether  at  home  or  in  a  hospital,  are  training, 
an  exacting  conscience,  and  genuine  concern  for  her  patient  as 
an  individual. 

A  certain  amount  of  scientific  knowledge  is  necessary,  in  this 
as  in  any  other  field,  to  give  the  nurse  an  intelligent  background 
and  a  kind  of  definiteness  and  stability  to  her  work.  She  should 
be  trained  in  the  essentials  of  general  nursing,  of  surgical  nurs- 
ing and  operating  room  technique,  and  in  the  care  of  babies. 
She  must  of  necessity  know  something  of  the  anatomy  and 
physiology  of  the  female  generative  organs;  the  physiological 
adjustments  during  pregnancy;  the  development  of  the  baby 
within  the  uterus;  the  normal  process,  or  mechanism,  of  labor, 
and  the  changes  which  ordinarily  take  place  during  the  puer- 


INTRODUCTION  9 

perium.  Such  information  will  make  clear  to  her  the  reasons 
for  the  care  which  she  gives  to  her  patient,  and  accordingly  her 
care  will  be  more  intelligent.  And  she  will  be  better  able  to 
recognize  the  difference  between  evidences  of  normal  physiolog- 
ical changes  and  the  symptoms  of  complications. 

Two  of  the  newer  branches  of  medicine — nutrition  and  men- 
tal hygiene  or  psychiatry — have  a  more  and  more  apparent 
relation  to  the  safety  and  welfare  of  the  maternity  patient,  and 
accordingly  are  of  moment  to  the  maternity  nurse.  For,  it 
must  be  remembered,  it  is  the  purpose  of  obstetricians  to-day  to 
establish  future  health  for  their  patients  as  well  as  immediate 
safety.  The  nurse  should  endeavor  to  help  with  all  that  the 
doctor  attempts  to  do  toward  these  ends,  and  in  order  to  help 
she  must  understand. 

The  maternity  nurse  can  scarcely  be  expected  to  specialize 
in  nutrition  or  in  psychiatry,  but  she  may  give  to  her  patients 
the  practical  benefits  of  many  valuable  discoveries  in  these  fields. 
She  may  not  be  able  to  remember,  for  example,  all  of  the  sources 
and  purposes  of  lime  in  the  diet,  nor  of  each  of  the  protective 
substances,  often  referred  to  as  vitamines,  but  any  nurse  can 
remember  and  be  guided  by  the  fact  that  her  patient  will  not 
be  satisfactorily  nourished  either  before  or  after  the  birth  of 
the  baby  unless  she  has  a  varied  diet  containing  milk,  eggs,  and 
green  vegetables.  She  also  can  explain  to  her  patients  that 
faulty  dietaries  are  responsible  for  the  tradition  that  each  child 
costs  the  mother  a  tooth,  as  well  as  the  fact  there  may  be  under- 
nourishment even  among  babies  who  are  fed  at  the  breast,  if 
the  mother's  diet  is  inadequate. 

And  though  the  mass  of  nurses  cannot  be  expected  to  grasp 
all  of  the  intricacies  of  psychiatry,  they  may  without  exception 
apply  one  of  its  most  important  principles  by  adopting  a  warm 
and  sympathetic  attitude  toward  their  patients  and  by  this 
means  win  their  trust  and  confidence.  The  restfulness  of  this; 
the  relaxation  and  general  state  of  mind  that  this  will  engender 
in  a  large  proportion  of  patients  will  exert  a  definitely  beneficial 
effect  upon  the  physical  well-being  of  the  expectant  mother,  the 
woman  in  labor  and  the  nursing  mother. 

These  simple  applications  of  important  scientific  discoveries 


10  INTRODUCTION 

that  relate  to  the  everyday  life  of  her  patient — these  are  things 
for  the  maternity  nurse  to  bear  in  mind.  She  is  nursing  a 
human  being  who  is  passing  through  crucial  periods  and  any- 
thing that  affects  her  as  a  human  being  affects  her  as  a  patient. 

Apparently,  then,  the  work  of  the  obstetrical  nurse  neces- 
sitates a  training  in  general  nursing  and  its  various  branches, 
in  addition  to  obstetrics,  for  there  seems  to  be  no  aspect  of  nurs- 
ing which  may  not,  under  some  condition,  have  its  place  in  the 
care  of  the  mother  or  her  baby.  All  of  this  training,  however,  will 
prepare  her  for  effective  work  only  if  she  herself  has  a  spirit  of 
eagerness  and  enthusiasm.  But  if  she  has  these  and  even  a 
little  training,  she  may  do  much. 

Accordingly,  let  the  nurse  who  has  been  prepared  by  a 
general  and  special  training,  and  who  wants  to  be  of  the  greatest 
possible  service  to  the  maternity  patient  start  by  appreciating  a 
few  general  principles  which  will  be  absolutely  indispensable 
to  the  success  of  her  work.  They  may  be  expressed  somewhat 
as  follows : 

1.  Cleanliness — under  all  conditions,  to  protect  both  mother 

and  baby  from  infection. 

2.  Watchfulness — for  early  symptoms  of  complications  in  either 

mother  or  baby. 

3.  Adaptability — to  the  patient,  the  doctor,  and  the  surround- 

ings. 

4.  Sympathy — for  every  mental  and  physical  stress  which  the 

patient  may  suffer. 
If  the  nurse  convinces  herself  of  the  import  of  these  requirements 
and  is  exacting  of  herself  in  giving  them  broad  interpretation, 
she  cannot  but  nurse  her  patients  well. 

She  will  appreciate  the  invariable  need  for  cleanliness  and 
watchfulness  if  she  will  hark  back  to  the  fact  that  our  mothers 
and  babies  die  in  distressingly  large  numbers  from  infections, 
toxaemias,  and  nutritional  disturbances,  all  of  which  are  usually 
amenable  to  preventive  or  early  treatment. 

In  order  to  be  always  clean,  always  watchful,  and  always 
ready  to  execute,  both  in  letter  and  spirit,  the  orders  of  doctors 
whose  methods  of  treatment  will  differ,  the  nurse  will  need 
to  be  very  adaptable.     She  will  need  to  keep   a  clear  head 


INTRODUCTION  11 

and  an  open  mind  and  to  remember  always  the  ends  that  are 
being  striven  for :  the  immediate  saf etj'  and  the  future  well- 
being  of  the  mother  and  the  baby.  And  she  may  rest  assured 
that,  no  mattei*  how  they  vary  as  to  details,  all  doctors  want 
all  of  their  patients  to  be  given  clean  care  ;  watched  for  symptoms 
of  complications;  and  given  good  general  nursing. 

Considering  the  need  for  cleanliness  in  a  very  broad  and 
practical  sense,  the  nurse  will  realize  that  the  test  of  her  ability 
to  protect  her  maternity  patients  from  infection  is  not  what 
she  is  able  to  do  in  a  hospital  where  there  is  every  facility  for 
clean  work.  It  is  not  the  ability  to  maintain  asepsis  in  a  tiled 
operating  room  that  counts,  where  she  is  aided  by  sterilizers, 
basins,  and  solutions  of  various  kinds  and  colors,  a  wealth  of 
ingenious  appliances  and  a  corps  of  co-workers.  It  is  the 
understanding  and  imagination  which  will  enable  her,  perhaps 
single-handed,  to  carry  the  principles  of  such  work  into  a 
patient's  home;  to  do  clean  work,  from  the  standpoint  of  avoid- 
ing infection,  in  a  mountain  hut  or  a  city  tenement  where 
everything  is  dirty. 

The  nurse  will  do  well  to  begin  to  develop  her  powers  of 
adaptability  while  she  is  still  in  training.  She  may  greatly 
increase  the  value  of  her  hospital  experience  by  trying  always 
to  understand  the  purpose  of  the  care  which  she  is  giving  and 
trying  at  the  same  time  to  imagine  how,  in  an  average  home, 
she  would  accomplish  the  results  of  this  or  that  procedure  which 
is  made  easy  of  execution  in  the  hospital  by  special  equipment. 
She  should  never  lose  sight  of  the  fact  that  she  is  not  being 
trained  solely  to  conform  to  any  one  hospital  routine  or  to 
become  expert  in  only  one  method  of  nursing  care.  She  is 
being  prepared  to  go  out  and  give  nursing  care  to  any  young 
woman  and  her  baby  who  need  it,  no  matter  Avhere  or  how  they 
are  situated  or  by  what  methods  they  are  treated. 

If  conditions  are  such  that  the  doctor's  orders  and  the 
patient's  requirements  seem  impossible  of  fulfillment,  then  the 
nurse  must  attempt  the  impossible  and  attempt  it  with  con- 
fidence of  success. 

It  is  clear  that  the  nurse  must  cultivate  adaptability  and 
resourcefulness  if  she  is  to  give  good  care  to  all  her  patients 


12  INTRODUCTION 

under  all  conditions.  But  even  the  most  efficient  and  intelli- 
gent work  will  not  be  wholly  satisfactory  unless  it  is  infused 
with  a  spirit  of  sympathy  for  the  woman  as  an  individual. 

The  thing  that  counts  in  this  connection  is  what  the  nurse, 
herself,  means  to  the  woman  who  is  facing  a  very  important 
and  mysterious  event,  who,  after  every  known  aid  has  been 
given,  must  still  go  through  a  great  deal  alone,  both  mentally 
and  physically.  It  is  not  helpful  to  a  woman  in  such  a  situa- 
tion to  be  told  that  women  have  borne  children  since  the  dawn 
of  Creation  and  that  they  all  have  had  pain;  that  she  will 
have  to  go  through  with  it,  as  they  have,  and  that  the  less 
fuss  she  makes  about  it  the  better.  But  it  does  help  her  to 
have  the  nurse  say  that  she  has  been  with  so  many  women  in 
labor  that  she  knows  they  suffer  intensely,  and  because  she 
knows  it  so  well  she  wants  to  do  all  that  lies  in  her  power  to 
give  even  a  little  relief.  The  nurse  may  never  know  just  how 
she  has  helped  and  reassured ;  how  a  pain  was  made  a  little  easier 
to  bear,  not  only  by  the  hand  slipped  under  an  aching  back,  but 
also  by  the  sympathy  that  the  act  conveyed.  But  she  may  be 
sure  that  she  has  helped. 

In  such  a  connection,  the  nurse  must  guard  against  the 
mistake  of  dividing  her  patients  into  well  defined  groups :  those 
who  are  poor  and  those  who  are  more  favored.  If  she  un- 
failingly looks  for  the  human  being  beyond  the  patient  she 
will  find  some  of  the  most  sensitive  and  appreciative  of  women 
among  the  simplest  and  poorest  and  they  will  be  warmly  re- 
sponsive to  a  thoughtful,  considerate  attitude.  And  at  the  same 
time,  the  patient  in  comfortable  circumstances  who  seems  to  be 
surrounded  by  all  that  one  could  desire,  is  often  pathetically 
lonely  and  isolated.  She,  too,  will  be  appreciative  of  encourage- 
ment and  an  attitude  of  concern  for  her  comfort. 

Suffering  and  anxiety  make  no  class  distinctions  and  have 
a  very  leveling  effect,  for  prince  and  pauper,  alike,  need  sym- 
pathy when  afflicted. 

From  the  standpoint  of  the  nurse  herself,  there  might  be 
discouragement  in  this  description  of  what  is  expected  of 
her,  and  what  are  her  opportunities  in  this  work  of  caring  for 
mothers  and  babies,  if  she  did  not  go  straight  to  tlie  heart  of 


INTRODUCTION  13 

the  matter  and  see  that  all  that  is  needed,  after  all,  is  good 
nursing.  She  must  realize,  of  course,  that  good  nursing  neces- 
sitates training  and  a  spirit  of  such  eager  service  that  she  will 
do  for  her  patient  all  that  lies  in  her  perhaps  limited  power, 
and  then  try  to  learn  of  still  more  that  she  may  offer.  And 
she  may  rest  assured  that  the  value  of  her  work  will  be  quite 
as  dependent  upon  such  a  spirit  as  upon  her  training. 

Obstetrical  nursing  may  be  defined,  with  accuracy,  as  the 
nursing  care  of  an  obstetrical  patient,  but  its  true  significance  is 
limited  only  by  the  nurse's  ability,  resourcefulness,  and  vision. 
And  the  more  spirituality  which  pervades  this  work  the  more 
effective  will  be  tlie  nurse's  skilled  ministrations  and  the  more 
satisfying  will  it  all  be  to  her. 

This  aspect  of  maternity  nursing — what  it  means  to  the 
nurse  herself — should  be  given  full  recognition,  for  although 
the  demands  which  are  made  upon  her  are  exacting,  she  will 
find  more  than  compensating  interest  and  gratification  in  her 
work. 

It  provides  a  channel  of  expression  for  some  of  her  most 
elemental  and  deeply  rooted  impulses.  The  desire  to  create 
exists  within  most  of  us,  and  surely  the  nurse  tastes  of  the 
joys  of  creation  when  she  watches  the  beautiful  baby  body 
grow  and  develop  under  her  care.  And  she  has  a  consciousness 
of  patriotic  service,  too,  for  while  helping  to  secure  the  im- 
mediate safety  and  future  health  of  the  baby  citizen  she  is 
helping  to  build  a  strong  race. 

But  this  work  goes  still  further  and  offers  even  more  than 
these. 

The  average  nurse  has  a  deep  maternal  instinct.  She  may 
not  be  conscious  of  it  as  such,  but  it  is  this  instinct  which 
prompts  her  to  select  nursing  from  the  wide  range  of  occupa- 
tions and  professions  which  are  open  to  her.  And  it  is  entirely 
natural  that  she  should  derive  great  satisfaction  from  this 
vicarious  motherhood — this  giving  of  her  knowledge  and  skill 
in  service  to  the  woman  with  a  baby  in  her  arms. 

The  opportunities  for  self-expression  which  are  open  to  the 
nurse  who  gives  this  form  of  service  make  us  wonder  if  she 
should  not  be  included  in  the  enviable  group  of  those  others 


14  INTRODUCTION 

whose  life  work  is  an  expression  of  themselves — the  poets  and 
painters;  the  architects,  musicians,  and  sculptors — those  who 
create  and  build  because  of  an  urge  within  them.  Surely,  the 
spirit  and  the  results  of  the  work  of  the  nurse  who  thus  gives  of 
herself  may  be  ranged  with  the  efforts  of  those  others  whose 
work  is  an  expression  of  tiiemselves. 


"The  body  is  the  crowning  marvel  in  the  world  of  miracles 
in  which  we  live.  Fearfully  and  wonderfully  made,  it  claims  our 
respect  not  only  because  God  fashioned  it,  but  because  He  fash- 
ioned it  so  well — because  it  is  a  thing  of  beauty,  a  perfection  of 
mechanism. ' ' 

The  Splendor  of  the  Human  Body — Bishop  Beent. 


PART  I 
ANATOMY  AND  PHYSIOLOGY 

CHAPTER  I.  ANATOMY  OF  THE  FEMALE  PELVIS  AND  GENERA- 
TIVE ORGANS.  Normal  Female  Pelvis.  Pelvimetry.  Female 
Organs  of  Reproduction.  Internal  Genitalia.  Uterus.  Fallopian 
Tubes.  Ovaries.  Vagina.  Bladder.  Rectum.  External  Genitalia. 
Mens  Veneris.  Labia  Majora.  Labia  Minora.  Vestibule.  Vaginal 
Opening.    Fossa  Navicularis.    Bartholin  Glands.    Perineum.    Breasts. 

CHAPTER  II.  PHYSIOLOGY,  Puberty.  Ovulation.  Menstruation. 
Modifications  of  Menstruation.     Menopause. 


CHAPTER  I 

ANATOMY  OP  THE  FEMALE  PELVIS  AND 
GENERATIVE  ORGANS 

NORMAL  FEMALE  PELVIS 

The  present  broad  knowledge  of  the  anatomy  of  tlie  female 
pelvis  has  resulted  in  an  enormous  reduction  in  death  and  in- 
jury amonp:  obstetrical  patients  and  tlieir  babies. 

This  knowledge  of  the  pelvic  anatomy,  relatinpj  as  it  does,  to 
both  normal  and  malformed  pelves,  has  made  possible  a  system 
of  taking  measurements,  termed  pelvimetry,  which  gives  the 
obstetrician  a  fair  idea  of  the  size  and  shape  of  his  ])atient's  pel- 
vis. Such  information,  coupled  with  observations  upon  the  size 
of  the  child's  head,  gives  a  foundation  upon  which  to  base  some 
expectation  of  the  ease  or  difficulty  with  which  the  approaching 
delivery  is  likely  to  be  accomplished. 

Since  each  patient's  pelvic  measurements  are  considered 
from  the  standpoint  of  tlieir  comparison  with  normal  dimensions, 
it  is  manifestly  important  that  the  obstetrical  nurse  have  a  clear 
idea  of  the  structure  of  the  normal  female  pelvis,  and  also  of 
its  commonest  variations. 

Viewed  in  its  entirety,  the  pelvis  is  an  irregularly  constructed, 
two-storied,  bony  cavity,  or  canal,  situated  below  and  support- 
ing the  movable  parts  of  the  spinal  column,  and  resting  upon 
the  femora  or  thigh  bones.     (Fig.  1,  A.  and  B.). 

Four  bones  enter  into  the  construction  of  the  pelvis :  the  two 
hip  bones  or  ossa  innominata,  on  the  sides  and  in  front  with  the 
sacrum  and  coccyx  behind. 

The  innominate  bones  (ossa  innominata),  symmetrical!}^ 
placed  on  each  side,  are  broad,  flaring  and  scoop-shaped.  Each 
bone  consists  of  three  main  parts,  which  are  separate  bones  in 
early  life,  but  firmly  welded  together  in  adults :  the  ilium,  ischium. 
and  pubis.  The  ilia  are  the  broad,  thin,  plate-like  sections  above, 

19 


20  OBSTETRICAL  NURSING 

their  upper,  anterior  prominences,  which  may  be  felt  as  the  hips, 
are  the  anterior  superior  spinous  processes  used  in  making  pelvic 
measurements.  The  margins  extending  backward  from  these 
points  are  termed  the  iliac  crests. 

The  ischii  are  below  and  it  is  upon  their  projections,  known 
as  the  tuberosities,  that  the  body  rests  when  in  the  sitting  posi- 
tion, and  which  also  serve  as  landmarks  in  pelvimetry.  The 
pubes  form  the  front  of  the  pelvic  wall,  the  anterior  rami  uniting 
in  the  median  line  by  means  of  heavy  cartilage  and  forming  the 
symphysis  pubis. 

The  sacrum  and  coccyx  behind  are  really  the  termination  of 
the  spinal  column,  the  sacrum  consisting,  usually,  of  five  rudi- 
mentary vertebrae  which  have  fused  into  one  bone.  It  some- 
times consists  of  four  bones,  sometimes  six,  but  more  often  of 
five.  The  sacrum  completes  the  pelvic  girdle  behind  by  uniting 
on  each  side  with  the  ossa  innominata  by  means  of  strong  car- 
tilages, thus  forming  the  sacro-iliac  joints.  The  spinal  column 
rests  upon  the  upper  surface  of  the  sacrum.  The  coccyx,  a  little 
wedge-shaped,  tail-like  appendage,  which  ordinarily  has  but 
slight  obstetrical  importance,  extends  in  a  downward  curve  from 
the  lower  margin  of  the  sacrum,  to  which  it  has  a  cartilaginous 
attachment,  the  sacro-coccygeal  joint.  This  joint  between  the 
sacrum  and  coccyx  is  much  more  movable  in  the  female  than  in 
the  male  pelvis. 

We  find,  therefore,  that  although  the  pelvis  constitutes  a 
rigid,  bony,  ringlike  structure,  there  are  four  joints:  the  sym- 
physis pubis,  the  sacro-coccygeal,  and  the  two  sacroiliac  articu- 
lations. As  the  cartilages  in  these  joints  become  somewhat  sof- 
tened and  thickened  during  pregnancy,  because  of  the  increased 
blood  supply,  they  all  permit  of  a  certain,  though  limited  amount 
of  motion  at  the  time  of  labor.  This  provision  is  of  consider- 
able obstetrical  importance,  since  the  sacro-coccygeal  joint  al- 
lows the  child's  head  to  push  back  the  forward-protruding  coc- 
cyx, as  it  passes  down  the  birth  canal,  thus  removing  what  other- 
wise might  be  a  serious  obstruction.  And  when,  as  is  some- 
times necessary,  because  of  a  constricted  inlet,  the  pubic  bone 
is  cut  through  (the  operation  known  as  pubiotomy),  the  hinge- 
like motion  of  the  sacro-iliac  joint  permits  of  an  appreciable 


ANATOMY 


21 


A.    Normal  female  Pelvis. 


B.     Normal  male  Pelvis. 

FlQ.  1. — Normal  Pelves.     Note  the  broad,  shallow,  light  construction  of  the 
female  pelvis-  A.  as  coiiipareJ  with  the  more  massive  male  pelvis,  B. 


22 


OBSTETRICAL  NURSING 


spreading  of  the  two  hip  bones  and  a  consequent  widening  of 
the  birth  canal. 

The  pelvic  cavity  as  a  whole  is  divided  into  the  true  and 
false  pelves  by  a  constriction  of  the  entire  structure  known  as 
the  brim  or  inlet.  The  inlet  is  not  round,  its  antero-posterior 
diameter  being  shortened  by  the  sacro-vertehral  joint  which 
protrudes  forward  and  gives  the  opening  something  of  a  blunt, 
heart-shaped  outline.     (Fig.  2.) 

As  the  pelvis  occupies  an  oblique  position  in  the  body,  the 
plane  of  this  brim  is  not  horizontal,  but  slopes  up  and  back  from 


Fig.  2. — Diagram  of  the  pelvic  inlet,  seen  from  above,  with  most  important 

diameters. 

the  symphysis-pubis  to  the  promontory  of  the  sacrum.  Being 
swung  upon  the  heads  of  the  femora,  the  relation  of  the  pelvis 
to  the  entire  body  differs  in  the  sitting  and  standing  positions. 
When  a  woman  stands  upright,  her  pelvis  is  so  markedly  oblique 
in  its  position  that  she  would  tip  backward  but  for  strong  ten- 
dons attached  to  the  pelvis  and  running  down  the  front  of  the 
thighs.  Added  strain  upon  these  tendons  during  pregnancy 
may  account  for  some  of  the  apparently  undue  fatigue  experi- 
enced by  the  expectant  mother. 

The  shallow,  expanded  portion  of  the  pelvis  above  the  brim 


ANATOMY 


23 


is  the  large,  or  false  pelvis,  its  walls  being  formed  by  the  sacrum 
behind,  the  fan-like  flares  of  the  ilia  on  each  side,  with  the  in- 
completeness of  the  bony  wall  in  front  made  up  by  abdominal' 
muscles. 

The  false  pelvis  ordinarily  serves  simply  as  a  support  for  the 
abdominal  viscera,  which  do  not  occupy  the  true  pelvis  unless 
forced  down  by  some  such  pressure  as  that  caused  by  tight,  or 
poorly  fitting  corsets.  The  false  pelvis  is  of  little  obstetrical  im- 
portance, its  function  during  pregnancy  being  to  support  the 
enlarged  uterus,  while  at  the  time  of  labor  it  acts  as  a  funnel 
to  direct  the  child's  body  into  the  true  pelvis  below. 


Fig.  3. — Diagram  of  pelvic  outlet,  seen  from  below,  with  most  important 

diameters. 


The  true  pelvis,  on  the  other  hand,  is  of  greatest  possible  ob- 
stetrical importance  since  the  child  must  pass  through  its  nar- 
row passage  during  birth.  It  lies  below  and  somewhat  behind 
the  inlet;  is  an  irregularly  shaped,  bottomless  basin,  and  con- 
tains the  generative  organs,  rectum  and  bladder.  Its  bony  walls 
are  more  complete  than  those  of  the  false  pelvis,  and  are  formed 
by  the  sacrum,  coccyx  and  innominate  bones.  Its  lower  margin 
constitutes  the  outlet,  or  inferior  strait,  and  l)eing  longer  in  its 
antero-posterior  dimension  than  in  its  transverse  measurement, 
its  long  axis  is  at  right  angles  to  the  long  axis  of  the  inlet.  (Fig. 
3.)  A  baby's  head,  accordingly,  must  twist  or  rotate  in  making 
its  descent  through  this  bony  canal,  for  the  long  diameter  of  the 
head  must  first  conform  to  one  of  the  long  diameters  of  the  in- 
let, either  transverse  or  oblique,  and  then  turn  so  that  the  length 


24  OBSTETRICAL  NURSING 

of  the  head  is  lying  antero-posteriorly,  in  conformity  to  the  long 
diameter  of  the  outlet,  through  which  it  next  passes. 

The  posterior  wall  of  the  pelvis,  consisting  of  the  sacrum 
and  coccyx,  forms  a  vertical  curve  and  is  about  three  times  as 
deep  as  the  anterior  wall  formed  by  the  narrow  symphysis 
pubis.     The  structure  as  a  whole,  therefore,  curves  upon  itself, 


Fig.  4. — Diagram  of  sagittal  section  of  the  pelvis  showing  curve  of  the 
bony  canal,  with  most  important  diameters. 

resembling  a  bent  tube  with  its  concavity  directed  forward. 
(Fig.  4.) 

Thus  it  becomes  apparent  that  the  structure  of  the  pelvis 
requires  the  child 's  head,  not  only  to  rotate  in  its  passage  through 
the  birth  canal,  but  also  to  describe  an  arc,  since  the  part  of  the 
head  which  passes  down  the  posterior  wall  travels  farther  in  a 
given  time  than  the"  part  which  passes  under  the  pubis. 

This  twisting  and  curving  of  the  bii'tli  canal  must  be  appre- 
ciated in  order  to  understand  the  mechanism  of  labor. 


ANATOMY 


25 


In  considering  the  question  of  pelvimetry,  we  find  that  there 
are  both  external  and  internal  measurements  to  be  taken,  all 
for  the  purpose  of  estimating  as  accurately  as  possible  the  short- 
est diameter  of  the  inlet  through  which  the  baby  must  pass. 
(Fig.  5.) 

According  to  a  common  system  of  mensuration,  the  first  ex- 
ternal measurement  is  the  inter-spinous,  the  distance  between 
the  anterior-superior  spines,  those  bony  points  which  are  upper- 


FiG.  5. — Two  types  of  pelvimeters  frequently  used  in  taking  measurementa 
of  the  pelvic  inlet  and  outlet. 


most  as  the  patient  lies  on  her  back.  This  distance  is  normally 
26  centimetres.     (Fig.  6.) 

The  second  measurement  is  the  inter-crestal,  or  the  distance 
between  the  iliac  crests,  and  is  normally  28  centimetres. 

Baudelocque's  diameter  is  the  third  measurement  and  is 
taken  with  the  patient  lying  on  her  side.  (Fig.  7.)  It  is  the  dis- 
tance from  the  top  of  the  symphysis  to  a  depression  just  below 
the  last  lumbar  vertebra.  This  depression  is  easily  located  as  it 
also  marks  the  upper  angle  of  a  space  just  above  the  buttocks, 
which  in  normal  pelves  is  quadrilateral.  In  malformed  pelves 
this  quadrangle  may  be  so  misshapen  as  to  become  almost  a 
triangle  with  the  apex  directed  either  up  or  down.    This  dimen- 


26 


OBSTETRICAL  NURSING 


sion  is  sometimes  called  the  external  conjugate  and  ordinarily 
measures  21  centimetres. 

The  fourth  measurement  is  the  distance  between  the  great 
trochanters,  or  heads  of  the  femora,  and  normally  is  32  centi- 
metres. 

All  of  these  measurements,  which  after  all  are  only  approxi- 
mate, relate  to  the  top  of  the  pelvis  and  are  valuable  in  that  they 


^     spl-nes 


Fig.   6.- 


Vockanjers 


-Diagram   showing  method   of   measuring   distances  between   iliac 
crests  and  spines  and  the  trochanters. 


help  in  estimating  the  dimensions  of  the  inlet,  which  are  the  im- 
portant ones,  and  obviously  cannot  be  measured  on  a  Ha^c  woman. 
The  inlet  has  four  measurements  of  obstetrical  importance: 
the  antero-posterior,  or  true  conjugate,  which  is  the  distance 
from  the  top  of  the  symphysis  pubis  to  the  prominence  of  the 
sacrum,  and  is  normally  11  centimetres;  the  transverse  diameter, 
which  is  at  right  angles  to  the  true  conjugate  and  is  the  greatest 
width  of  the  inlet,  measuring  from  a  point  on  one  side  of  the 
brim  to  the  corresponding  point  on  the  other,  is  normally  13.5 
centimetres,  and  the  two  diagonal  measurements,  known  respec- 


ANATOMY 


27 


tively  as  the  right  and  left  oblique  diameters,  which  are  nor- 
mally 12.75  centimetres. 

Although  it  is  very  important  to  the  expectant  mother  that 
all  of  these  dimensions  be  of  normal  length,  the  length  of  the  true 
conjugate,  or  conjugata  vera,  is  of  the  gravest  importance  of  all 
because  it  is  the  shortest  diameter  through  which  the  child's  head 
must  i)ass.  If  it  is  shorter  than  normal,  the  ('lianncl  may  be  too 
constricted  for  the  full-term  l)al)y's  head  to  pass  through  com- 


udeloc^ue'a 
dlomeler  gicm. 


Fig.  7. — Diagram  showing  method  of  measuring   Baudelocque 's  diameter. 

fortably,  thus  making  a  spontaneous  delivery  extremely  difficult, 
or  even  impossible. 

The  length  of  the  all  important,  true  conjugate  is  estimated 
by  introducing  the  first  two  fingers  of  one  hand  into  the  vagina 
until  the  tip  of  the  second  finger  touches  the  promontory  of  the 
sacrum.  (Fig.  8.)  The  point  at  which  the  inner  margin  of 
the  sjTuphysis  then  rests  upon  the  forefinger  is  measured,  thus 
giving  the  length  of  the  diagonal  conjugate.  This  normally 
measures  12.5  centimetres  or  more,  and  is  estimated  as  being  1.5 
centimetres  longer  than  the  true  conjugate. 


28 


OBSTETRICAL  NURSING 


The  most  important  measurement  of  the  outlet  is  the  inter- 
tuberous  diameter,  the  distance  between  the  tuberosities  of  the 
ischii.  This  is  the  shortest  diameter  through  which  the  child 
must  pass  in  the  inferior  strait,  and  normally  measures  some- 
thing more  than  8  centimetres,  usually  about  11  centimetres. 
(Fig.  9.) 

It  is  possible,  by  studying  such  measurements  as  these,  made 
upon  an  expectant  mother,  and  comparing  them  with  dimensions 
which  have  been  accepted  as  normal,  to  form  a  reasonably  ac- 
curate estimate  of  the  size  and  shape  of  her  pelvis. 


^^_7rue  conjugate 


Fig.    8. — Diagram    showing   method    of   estimating   the   true   conjugate   by 
measuring   the   length   of  the   diagonal  conjugate. 

A  delivery  may  be,  and  frequently  is,  accomplished  through 
a  pelvis  which  is  not  entirely  normal  in  size  or  shape.  But  the 
obstetrician  of  to-day  is  closely  observant  of  the  patient  whose 
pelvic  measurements  depart  from  the  normal  by  more  than  the 
accepted  margin  of  safety,  and  he  plans  for  labor  in  accordance 
with  the  indications  in  each  case. 

Disproportion  between  the  measurements  of  the  mother's 
pelvis  and  the  size  of  the  child 's  head  must  be  considered  in  this 
connection.  A  small  pelvis  may  permit  of  the  spontaneous  de- 
livery of  a  small  child,  but  be  too  narrow  for  the  passage  of  a 


ANATOMY 


29 


full-sized  baby,  while  a  woman  with  a  normal  pelvis  may  have 
an  extremely  diffii'ult  labor  because  of  an  unusually  large  child. 
The  size  and  shape  of  the  pelvis  is  found  to  vary  among  dif- 
ferent races  and  in  different  individuals.  And  the  size  and  con- 
tour of  the  inlet  may  be  so  altered  by  rickets,  lack  of  proper 
exercise  during  early  life,  or  by  growths  upon  the  pelvic  bones, 
as  to  seriously  interfere  with  normal  labor. 


Fig.  9. — Diagram  showing  method  of  measuring  the  inter-tuberous  diameter. 


The  various  kinds  of  malformed  pelves  may  be  loosely  clas- 
sified as  generally  contracted  or  small ;  flat ;  simple  funnel ;  gen- 
erally contracted  funnel ;  and  the  rachitic  pelves,  both  flat  and 
generally  contracted.  There  may  be  a  contracted  inlet,  or  a  con- 
tracted outlet,  or  both  may  occur  in  the  same  pelvis.* 

*  In  the  generally  contracted  pelves,  all  of  the  external  measurements 
are  shorter  than  normal,  the  diagonal  conjugate  being  11.5  cm.,  or  less.  In 
simple  flat  pelves,  on  the  other  hand,  the  external  measurements  are  normal, 
but  the  diagonal  conjugate  is  11  cm.,  or  less. 

If  the  distance  between  the  tuher-ischii  is  only  8  cm.,  or  less,  the  patient 


30  OBSTETRICAL  NURSING 

Rachitic  pelves  are  common  among  negroes  and  not  alto- 
gether rare  among  white  women. 

The  normal  male  pelvis  is  deep,  narrow,  rough  and  massive 
as  compared  with  the  female  structure  (see  Fig.  1.),  and  the 
angle  of  the  pubic  arch,  formed  by  the  two  pubic  bones,  is  deeper 
and  more  acute  in  the  male  than  in  the  female  skeleton. 

The  normal  female  pelvis,  on  the  other  hand,  is  light,  broad, 
shallow,  smooth  and  large,  giving  evidence  of  the  infinite  wis- 
dom and  skill  that  entered  into  constructing  it  for  the  high  pur- 
pose it  was  designed  to  serve. 

FEMALE  ORGANS  OF  REPRODUCTION 

The  female  organs  of  reproduction  are  divided  into  two 
groups,  the  internal  and  the  external  genitals.  With  them  are 
usually  considered  certain  other  structures:  the  ureters,  Mad- 
der, urethra,  rectum  and  the  perineum,  because  of  their  close 
proximity  (Fig.  10.)  ;  and  the  breasts,  because  of  their  func- 
tional relation  to  the  reproductive  organs. 

Internal  Genitalia.  The  internal  organs  of  generation  are 
contained  in  the  true  pelvic  cavity  and  comprise  the  uterus  and 
vagina  in  the  centre,  an  ovary  and  Fallopian  tube  on  each  side, 
together  with  their  various  ligaments,  membranes,  nerves  and 
blood  vessels  and  a  certain  amount  of  frt  and  connective  tissue. 

The  uterus  is  the  largest  of  these  organs.    In  its  nonpregnant 

has  some  kind  of  a  funnel  pelvis;  simple,  if  the  inlet  measurements  are 
normal,  but  if  they  also  are  shortened,  the  pelvis  is  described  as  a  generally 
contracted  funnel. 

The  rachitic  pelves  present  certain  characteristic  features,  one  being 
less  difference  between  the  inter-spinous  and  inter-crestal  measurements 
than  is  found  in  a  normal  pelvis.  Another,  that  the  distance  between  the 
tuber-ischii  is  always  of  normal  length  and  may  even  be  greater  than 
normal.  The  peculiar  deformity  of  the  sacrum,  however,  is  the  most 
characteristic  abnormality  of  the  rachitic  pelves.  The  concavity  from  above 
downward  is  markedly  increased,  in  some  cases  almost  forming  an  angle, 
while  the  horizontal  concavity  is  nearly  or  quite  obliterated.  The  com- 
monest type  of  a  rachitic  pelvis  is  one  in  which  all  of  the  inlet  measure- 
ments are  shortened,  the  inter-tuberous  distance  normal,  and  the  sacrum 
characteristically  deformed.  This  is  called  the  generally  contracted,  rachitic 
pelvis.  In  the  flat  rachitic  pelvis  all  of  the  inlet  measurements  are 
normal,  except  the  diagonal  conjugate,  which  may  be  shortened  to  11  cm., 
or  less,  and  the  sacrum  presents  the  deformity  described  above. 


ANATOMY 


31 


state,  it  is  a  hollow,  flattened,. pear-shaped  organ  about  three 
inches  long,  one  and  a  quarter  inches  wide,  at  its  broadest  poipt, 
three-quarters  of  an  inch  tliick  and  weighing  about  two  ounces. 


Fig.  10. — Anterior  view  of  female  tfeuerative  tract,  showing  both  ex- 
ternal and  internal  organs.  Drawn  by  Max  Brodel.  (Used  by  permission 
of  A.  J.  Nystrom  &  Co.,  Chicago.) 

Ordinarily  it  is  a  firm,  liard  mass,  consisting  of  irregularly 
disposed,  involuntary  (unstriped  or  plain)  muscle  fibres  and 
"onnective  tissue,  nerves  and  blood  vessels.     The  arrangement 


32 


OBSTETRICAL  NURSING 


of  the  utorine  muscle  fibres  is  unique,  for  they  run  up  and  down, 
around  and  crisscross,  forming  a  veritable  network.  This  strange 
arrangement  of  the  fibres  is  favorable  to  the  growth  of  the  uter- 
ine musclature  during  pregnancy,  and  a  factor  in  preventing 
hemorrhage  after  delivery. 

The  abundant  blood  supply  to  the  uterus  merits  a  word.  It 
is  derived  from  the  uterine  arteries,  arising  from  the  internal 
iliacs,  and  the  ovarian  artery  from  the  aorta.  The  arteries  from 
the  two  sides  of  the  uterus  are  united  by  a  branch  where  the 
neck  and  body  of  this  organ  meet,  thus  forming  an  encircling 


Lateral    secUon 
of  virgin  uterus 


Lateral    section 
of  multlparous  uterus 


Antero- posterior     section 

Fig.  11. — Diagrams  of  sections  of  virgin  and  multiparous  uteri 


artery.  A  deep  cervical  tear  during  labor  may  break  this  vessel 
and  a  profuse  hemorrhage  occur  as  a  result. 

The  uterus  is  covered,  front  and  back,  by  a  fold  of  the  peri- 
toneum, except  the  lower  part  of  the  anterior  wall  where  the 
peritoneum  is  reflected  up  over  the  bladder.  It  is  lined  with  a 
thick,  velvety,  highly  vascular  mucous  membrane,  the  endome- 
trium, the  surface  of  which  is  covered  by  ciliated,  columnar 
epithelium.  Embedded  in  the  endometrium  are  numerous  mu- 
cous glands  which  dip  down  into  the  underlying,  muscular  wall. 

The  uterus  as  a  whole  is  comprised  of  three  parts :  the  fundus, 
that  firm,  rounded,  head-like  part  above;  the  body,  or  middle 
portion,  and  the  cervix,  or  neck,  below.  It  is  in  the  body  and  cer- 
vix that  we  find  the  long,  narrow  uterine  cavity,  divided  by  a 
constriction  into  two  parts.  The  cavity  of  the  body  is  little 
more  than  a  vertical  slit,  being  so  flattened  from  before  backward 


ANATOMY  33 

that  the  anterior  and  posterior  surfaces  are  nearly  if  not  quite 
in  apposition.  It  is  somewhat  triangular  in  sliape  with  an  open- 
ing at  each  angle.  (Fig.  11.)  The  h)wer  of  tliese  openings  leads 
into  the  cavity  of  the  cervix  through  a  constriction  termed  the 
internal  os,  while  at  the  cornua,  or  two  upper  angles,  are  the 
openings  into  the  Fallopian  tubes. 

The  cavity  of  the  cervix  is  spindle-shaped,  being  expanded 
between  its  two  constricted  openings,  the  internal  os  above  and 
the  external  os  below,  which  opens  into  the  vagina.  The  exter- 
nal OS  in  the  virgin  is  a  small  round  hole  but  has  a  ragged  outline 
in  women  who  have  borne  children. 

This  oblong,  muscular  body,  the  uterus,  is  suspended  ob- 
liquely in  the  centre  of  the  pelvic  cavity  by  means  of  ligaments. 
In  its  normal  position  the  entire  organ  is  slightly  curved  forward, 
or  ante-flexed,  the  fundus  being  directed  upward  and  forward 
and  the  cervix  pointing  down  and  back.  This  position  is  affected 
by  a  distended  bladder  or  rectum,  and  also  by  postural  changes 
in  the  body  as  a  whole.  The  cervix  protrudes  into  the  anterior 
wall  of  the  vagina  for  about  one-half  inch  and  almost  at  right 
angles,  since  the  vagina  slopes  down  and  forward  to  the  outlet. 

The  upper  part  of  the  uterus  is  held  in  position  by  means  of 
ligaments,  the  lower  part  being  imbedded  in  fat  and  connective 
tissue  between  the  bladder  and  rectum.  This  more  or  less  ot  a 
floating  position  makes  possible  the  enormous  increase  in  size 
and  upward  push  or  extension  of  the  uterus  during  pregnancy. 
The  pregnant  uterus  becomes  soft  and  elastic  as  it  grows.  At 
term  it  is  about  a  foot  long,  eight  to  ten  inches  wide,  and  reaches 
up  into  the  epigastric  region.  This  growth  is  due  in  part  to  the 
development  of  new  muscle  fibres  and  in  part  to  a  growth  of  the 
fibres  already  existing  in  the  uterine  wall. 

After  labor  the  uterus  returns  almost,  but  never  entirely,  to 
its  former  size,  shape  and  general  condition. 

The  Fallopian  tubes  are  two  tortuous,  muscular  tubes,  four 
or  five  inches  long,  extending  laterally  in  an  upward  curve,  from 
the  cornua  of  the  uterus  and  within  the  folds  of  the  upper  mar- 
gin of  the  broad  ligament,  by  which  they  are  covered.  At  their 
juncture  with  the  uterus,  the  diameter  of  these  tubes  is  so  small 
as  to  admit  of  the  introduction  of  only  a  fine  bristle,  but  they 


34  OBSTETRICAL  NURSING 

gradually  increase  in  size  toward  their  termination  in  wide 
trumpet-shaped  orifices,  which  open  directly  into  the  peritoneal 
cavity.  Finger-like  projections  called  fimbrice,  fringe  the  mar- 
gins of  these  openings. 

The  mucous  lining  of  the  tubes  is  covered  with  ciliated  epithe- 
lium and  is  continuous  with  that  of  the  uterus.  At  the  fimbriated 
extremities  of  the  tubes  this  lining  merges  into  the  peritoneum, 
the  serous  lining  of  the  abdominal  cavity. 

Just  here  it  will  be  well  to  say  a  word  about  the  peritoneum 
because  of  the  possibility  of  its  becoming  infected  during  labor 
and  the  lying-in  period,  and  the  very  grave  consequences  of  such 
infection.  It  is  a  delicate,  highly  vascular,  serous  membrane 
which  both  lines  the  abdominal  cavity  and  covers  the  abdominal 
and  pelvic  organs,  which  press  into  its  outer  surface  and  are 
covered  much  as  one 's  fingers  would  be  covered  by  pushing  them 
into  the  outer  surface  of  a  child 's  toy  balloon.  The  continuity  of 
this  membrane  is  broken  only  where  it  is  entered  by  the  Fallopian 
tubes. 

The  ovary,  the  sex  gland  of  the  female,  is  a  small,  tough  duet- 
less  gland,  about  an  inch  long  and  three-quarters  of  an  inch  wide, 
or  about  the  size  and  shape  of  an  almond.  It  is  greyish  pink  in 
color  and  presents  a  more  or  less  irregular,  dimpled  surface.  An 
ovary  is  suspended  on  either  side  of  the  uterus,  in  the  posterior 
fold  of  the  broad  ligament,  by  which  it  is  partly  covered.  Its 
outer  end  is  usually  attached  to  the  longest  of  the  fimbriated 
extremities  of  the  Fallopian  tube,  the  fimhria  ovarica,  which  has 
the  form  of  a  shallow  gutter,  or  groove.  The  inner  end  of  the 
ovary  is  attached  to  the  ovarian  ligament,  which  in  turn  is  at- 
tached to  the  uterus  below  and  behind  the  tubal  entrance. 

The  ovary  consists  of  two  parts,  the  central  part  or  medulla, 
composed  of  connective  tissue,  nerves,  blood  and  lymph  ves- 
sels, and  the  cortex,  in  which  are  embedded  the  vesicular  Graa- 
fian follicles  containing  the  ova.  At  birth  each  ovary  contains 
upwards  of  50,000  of  these  ova,  which  are  the  germ  cells  con- 
cerned with  reproduction  and  the  process  of  menstruation. 

These  ovarian  glands  perform  two  vital  functions,  for  in 
addition  to  their  prime  function  of  producing  and  maturing  the 
germinal  cell  of  the  female,  they  provide  an  internal  secretion 


ANATOMY 


35 


which  exercises  an  immeasurably  important,  though  imperfectly 
understood,  influence  upon  the  general  well-being  of  the  entire 
organism. 

The  vagina  is  an  elastic,  muscular  sheath  or  tube,  about  four 


Fig.   12. — Sagittal    section   of    female   generative   tract.     Drawn   by   Max 
Brodel.     (Used  by  permission  of  A.  J.  Nystrom  &  Co.,  Chicago.) 

inches  long,  lying  behind  the  bladder  and  urethra  and  in  front  of 
the  rectum.  It  leads  interiorly  up  and  backward  from  the  vulva 
to  the  cervix,  which  it  encases  for  about  half  an  inch.  The  space 
between  the  outer  surface  of  the  cervix  that  extends  into  the 
vagina,  and  the  surrounding  vaginal  walls,  is  called  the  formx. 


36  OBSTETRICAL  NURSING 

For  convenience  of  description,  this  is  divided  into  four  sections 
or  f ornices :  the  anterior,  posterior  and  lateral  f ornices. 

Between  the  posterior  fornix  and  the  rectum  a  fold  of  the 
peritoneum  drops  down  and  forms  a  blind  pouch  known  as 
Douglas'  cul-de-sac.  At  this  point  the  delicate  peritoneum  is 
separated  from  the  vagina  by  only  a  thin,  easily  punctured,  mus- 
cular wall.  This  is  a  fact  of  grave  surgical  significance,  for  un- 
less instruments  and  nozzles  introduced  into  the  vagina  are  very 
gently  and  skillfully  directed,  they  may  easily  pierce  this  thin 
partition.  Septic  material  may  thus  gain  entrance  to  the  peri- 
toneal cavity  and  peritonitis  result. 

The  bore  of  the  vaginal  canal  ordinarily  permits  of  the  intro- 
duction of  one  or  two  fingers.  It  is  somewhat  flattened  from  be- 
fore backward,  and  on  cross  section  resembles  the  letter  H.  Dur- 
ing labor  this  canal  becomes  enormously  dilated,  being  then  four 
or  five  inches  in  diameter,  and  permits  the  passage  of  the  full 
term  child. 

The  vagina  is  lined  with  a  thick,  heavy,  mucous  membrane 
which  normally  lies  in  transverse  folds  or  corrugations  called 
rugce.  These  folds  are  obliterated  and  the  lining  stretched  into 
a  smooth  surface  as  the  canal  dilates  during  labor. 

Attention  must  be  drawn  to  the  fact  that  the  vagina,  cervix, 
uterus  and  tubes  form  a  continuous  canal  from  the  vulva  to  the 
easily  infected  peritoneum,  a  fact  which  makes  absolute  surgical 
cleanliness  in  obstetrics  virtually  a  matter  of  life  or  death  to 
the  patient. 

This  muscular  tube  is  lined  throughout  its  entire  length  with 
mucous  membrane,  which,  though  continuous,  changes  some- 
what in  character  along  its  course.  The  epithelial  cells  of  the 
lining  of  the  tubes  and  body  of  the  uterus  have  hair-like  projec- 
tions, ciliae,  which  maintain  a  constant  waving  motion  from 
above  downward.  The  effect  of  this  sweeping  current  is  to  carry 
down  toward  the  outlet  any  object  or  secretion  which  may  be 
upon  the  surface  of  the  lining  of  the  tubes  or  uterine  cavity. 
The  unfertilized  ovum  is  thus  swept  down  to  meet  the  germ  cell 
of  the  male  and  become  fertilized. 

Along  this  variously  constructed  canal,  at  different  periods 
in  the  life  of  the  individual,  pass  the  matured  ovum,  the  men- 


ANATOMY  37 

strual  flow,  the  uterine  secretions,  the  fetus,  the  placenta  and 
lochia,  (the  discharge  Avhich  occurs  during  tlie  puer])erium). 

Although  the  bladder  and  rectum  are  not  organs  of  repro- 
duction, they  are  contained  in  the  pelvic  cavity  and  lie  in  such 
close  proximity  to  the  internal  genitalia  that  at  least  a  passing 
word  must  be  devoted  to  their  description. 

The  bladder  is  a  sac  of  connective  tissue  which  serves  as  a 
reservoir  for  the  urine  and  is  situated  behind  the  symphysis  pubis 
and  in  front  of  the  uterus  and  vagina.  Urine  is  conducted  into 
the  bladder  by  the  ureters,  two  slender  tubes  running  down  on 
each  side  from  the  basin  of  the  kidney  across  the  pelvic  brim  to 
the  upper  part  of  the  bladder,  which  they  enter  somewhat 
obliquely,  at  about  the  level  of  the  cervix.  It  is  thought  that 
pressure  of  the  enlarged  pregnant  uterus  upon  the  ureters  at 
this  point  may  be  one  factor  in  the  causation  of  pyelitis,  a  fre- 
quent complication  of  pregnancy.  The  bladder  empties  itself 
through  the  urethra,  a  short  tube  which  terminates  in  the  meatus 
urinarius,  a  tiny  opening  in  the  vulva. 

The  rectum,  the  lowest  segment  of  the  intestinal  tract,  is 
situated  in  the  pelvic  cavity  behind  and  to  the  left  of  the  uterus 
and  vagina.  It  extends  downward  from  the  sigmoid  flexure  of 
the  colon  to  its  termination  in  the  anal  opening.  The  anus  is 
a  deeply  pigmented,  puckered  opening  situated  an  inch  and  a 
half  or  two  inches  behind  the  vagina.  It  is  guarded  by  two 
bands  of  strong  circular  muscles,  the  internal  and  external 
sphincter  ani.  The  skin  covering  the  surface  of  the  body  extends 
upward  into  the  anus  where  it  becomes  highly  vascular  and 
merges  into  the  mucous  lining  of  the  rectum.  Pressure  exerted 
during  pregnancy  by  the  enlarged  uterus  is  felt  in  both  the  rec- 
tum and  bladder,  frequently  causing  a  good  deal  of  discomfort 
and  almost  painful  desire  to  evacuate  their  contents. 

The  blood  vessels  in  the  anal  lining  just  within  the  external 
sphincter  sometimes  become  engorged  and  inflamed,  even  bleed- 
ing during  pregnancy,  as  a  result  of  the  pressure  exerted  by  the 
greatly  enlarged  uterus.  The  distended  blood  vessels,  which  in 
this  condition  are  called  hemorrhoids,  not  infrequently  protrude 
from  the  anus  and  become  very  painful. 


38  OBSTETRICAL  NURSING 

After  having  considered  the  structure  and  relative  positions 
of  the  pelvic  organs  one  is  able  to  picture  more  clearly  the  ar- 
rangement and  disposition  of  the  uterine  ligaments,  all  of  which 
are  formed  by  folds  of  the  peritoneum.  They  are  twelve  in  num- 
ber, five  pairs  and  two  single  ligaments,  namely :  tw'o  broad,  two 
round,  two  utero-sacral,  two  utero-vesical,  two  ovarian,  one  an- 
terior and  one  posterior  ligament. 

The  broad  ligaments  are  in  reality  one  continuous  structure 
formed  by  a  fold  of  the  peritoneum,  w^hich  drops  down  over  the 
uterus,  investing  the  fundus,  body,  part  of  the  cervix,  and  part 
of  the  posterior  wall  of  the  vagina.  It  unites  on  each  side  of  the 
uterus  to  form  a  broad,  flat  membrane  which  extends  laterally  to 
the  pelvic  wall,  dividing  the  pelvic  basin  into  an  anterior  and 
posterior  compartment,  containing  respectively  the  bladder  and 
rectum.  Between  the  folds  of  the  broad  ligament  are  situated  the 
ovaries  and  ovarian  ligaments,  the  Fallopian  tubes,  the  round 
ligaments  and  a  certain  amount  of  muscle  and  connective  tissue, 
blood  vessels,  lymphatics  and  nerves. 

The  round  ligaments,  one  on  each  side,  are  narrow,  flat  bands 
of  connective  tissue  derived  from  the  peritoneum  and  muscle 
prolonged  from  the  uterus,  and  containing  blood ^and  lymph  ves- 
sels and  nerves.  They  pass  upward  and  forward  from  their  uter- 
ine origin  just  below  and  in  front  of  the  tubal  entrance,  finally 
merging  in  the  mons  veneris  and  labia  majora. 

The  utero-sacral  ligaments,  of  which  there  is  one  on  each 
side,  arise  in  the  uterus  and,  extending  backward,  serve  to  con- 
nect the  cervix  and  vagina  with  the  sacrum. 

The  utero-vesical  ligaments,  one  on  each  side,  extend  forward 
and  connect  the  uterus  and  bladder. 

The  ovarian  ligaments,  as  previously  described,  are  attached 
to  the  uterine  wall  and  to  the  inner  end  of  the  ovary,  one  on 
each  side. 

The  anterior  ligament  is  a  portion  of  the  peritoneum  which 
dips  down  between  the  bladder  and  uterus,  forming  a  pouch.  It 
is  known  also  as  the  uterine-vesical  pouch,  or  the  vesico-uterine 
excavation. 

The  posterior  ligament  is  formed  in  much  the  same  manner 
by  a  portion  of  the  peritoneum  dipping  down  behind  the  uterus, 


ANATOMY 


39 


in  front  of  the  rectum,  and  forming  the  recto-vaginal  pouch. 
This  is  the  Doughis'  cul-de-sac  previously  referred  to. 

ExtemaJ  Genitalia. — The  vulva,  or  external  genitalia,  are 
situated  in  the  pudendal  crease  which  lies  between  the  thighs  at 
their  junction  with  the  torso,  and  extends  posteriorly  from  the 
pubis  to  a  point  well  up  on  the  sacrum.     (Fig.  13.) 

The  mons  veneris  is  a  firm  cushion  of  fat  and  connective  tis- 
sue, just  over  the  symphysis  pubis.  It  is  covered  with  skin  wiiich 
contains  many  sebaceous  glands  and  after  puberty  is  abundantly 
covered  with  hair. 

The  labia  majora  are  heavy  ridges  of  fat  and  connective  tis- 
sue, prolonged  from  the  mons  veneris  and  extended  down  and 


Fossa  navicuVarls  _  ^Sjj 


FiG.  13. — Diagram  of  external  female  genitalia.  (Redrawn  from  Dickinson.) 


back  almost  to  the  rectum,  on  each  side,  forming  the  lateral 
boundaries  of  the  groove.  They  are  lined  with  mucous  mem- 
brane and  covered  with  skin  and  hair,  the  latter  growing  thinner 
toward  the  perineum  until  it  finally  disappears. 

The  labia  minora  are  two  small  cutaneous  folds  lying  between 
the  labia  majora  on  each  side  of  the  vagina.     Like  the  larger 


40  OBSTETRICAL  NURSING 

folds,  they  taper  toward  the  back  and  practically  disap- 
pear in  the  vaginal  wall.  Their  attenuated  posterior  ends  are 
joined  together  behind  the  vagina  by  means  of  a  thin,  flat  fold 
called  the  fourchette.  The  labia  minora  divide  for  a  short  dis- 
tance before  joining  at  an  angle  in  front,  thus  forming  a  double 
ridge  anteriorly.  In  the  depression  between  these  ridges  is  the 
clitoris y  a  small,  sensitive  projection  composed  of  erectile  tissue, 
nerves  and  blood  vessels  and  covered  with  mucous  membrane. 
The  meatus  urinarius  is  just  below  the  clitoris  and  between  two 
small  folds  of  the  mucous  membrane. 

The  vestibule  is  the  triangular  space  between  the  labia 
minora,  and  into  it  open  the  meatus  urinarius,  the  vagina  and 
the  more  important  vulvo-vaginal  glands. 

The  vaginal  opening*  is  below  the  vestibule  and  above  the 
perineum.  It  is  partially  closed  by  the  hymen,  a  fold  of  mucous 
membrane  disposed  irregularly  around  the  outlet,  somewhat  af- 
ter the  fashion  of  a  circular  curtain.  The  hymen  is  ragged  or 
more  or  less  scalloped  in  outline,  and  varies  greatly  in  size  in 
different  women,  in  some  instances  extending  so  far  over  the 
opening  as  nearly  or  quite  to  close  it.  ^ 

The  fossa  navicularis  is  a  depressed  space  between  the  hymen 
and  fourchette,  so  named  because  of  its  boat-like  shape. 

The  Bartholin  glands,  probably  the  largest  and  most  impor- 
tant of  the  vulvo-vaginal  glands,  are  situated  one  on  each  side 
of  the  vagina  and  open  into  the  groove  between  the  hymen  and 
labia  minora.  Reference  is  made  to  these  glands  because  of  the 
danger  of  their  becoming  infected.  A  gonorrheal  infection  of 
these  glands  is  particularly  troublesome. 

The  perineum  is  a  pyramidal  structure  of  connective  tissue 
and  muscle  which  occupies  the  space  between  the  rectum  and 
vagina,  and  by  forming  the  floor  of  the  pelvis  serves  as  a  sup- 
port for  the  pelvic  organs.  The  lower  and  outer  surface  of  this 
mass,  representing  the  base  of  the  pyramid,  lies  between  the 
vaginal  opening  and  the  anus  and  is  covered  with  skin.  As  the 
anterior  part  of  the  perineum  is  incorporated  in  the  posterior 
wall  of  the  vagina,  the  entire  structure  becomes  stretched  and 
flattened  when  the  vagina  is  dilated  during  labor  by  the  pas- 
sage of  the  child's  head. 


ANATOMY  41 

Unless  very  carefully  guarded  at  the  time  of  delivery,  and 
often  even  then,  the  perineum  gives  way  under  the  great  tension 
undergone  at  that  time,  and  a  tear  is  the  result.  The  injury  may 
be  only  a  slight  nick  in  the  mucous  membrane  or  it  may  extend 
to,  or  into  the  levator  am,  the  most  important  muscle  of  the  peri- 
neal body,  or  if  a  "complete  tear"  will  extend  all  the  way 
through  the  perineum  and  completely  through  the  sphincter  ani. 
Such  a  tear  is  lamentable,  as  a  break  in  the  ring-shaped  sphincter 
muscle  guarding  the  anal  opening  robs  a  woman  of  control  of  her 
bowels,  and  is  repaired  with  difficulty. 

BREASTS 

The  breasts  are  large,  specially  modified  skin  glands  of  the 
compound,  racemose  or  clustering  type,  embedded  in  fat  a_iid 
connective  tissue  and  abundantly  supplied  with  nerves  and 
blood  vessels.  They  are  situated  quite  remotely  from  the  pelvic 
organs,  but  because  of  the  intimate  functional  relation  between 
the  two,  the  breasts  of  the  female  may  be  regarded  as  accessory 
glands  of  the  generative  system.  They  exist  in  the  male,  also,  but 
only  in  a  rudimentary  state. 

Although  the  breasts  sometimes  contain  milk  during  in- 
fancy, their  true  function  is  to  secrete,  in  the  parturient  woman, 
suitable  nourishment  for  the  human  infant  during  the  first 
few  months  of  its  life. 

These  glands  are  symmetrically  placed,  one  on  each  side  of  the 
chest,  and  occupy  the  space  between  the  second  and  sixth  ribs 
extending  from  the  margin  of  the  sternum  almost  to  the  mid- 
axillary  line.  A  bed  of  connective  tissue  separates  them  from 
the  underlying  muscles  and  the  ribs.     (Fig.  14.) 

They  vary  in  size  and  shape  at  different  ages,  and  with  dif- 
ferent individuals,  particularly  in  women  who  have  borne  and 
nursed  children,  when  they  tend  to  become  pendulous.  But  in 
general  they  are  hemispherical  or  conical  in  shape  with  the  nip- 
ple portruding  from  one-quarter  to  one-half  inch  from  the  apex. 
The  nipples  are  largely  composed  of  sensitive,  erectile  tissue  and 
become  more  rigid  and  prominent  during  pregnancy  and  at  the 
menstrual  periods.  Their  surfaces  are  pierced  by  the  orifices  of 
the  milk  ducts,  which  are  fifteen  or  twenty  in  number.    (Fig.  15.) 


42 


OBSTETRICAL  NURSING 


Milk  duclW 


Lacteal  orifices 


3"T?lb 


6IsT?lb 


Fig.   14.-Sagittal   section  of   breast   showing   structure  of   « 

apparatus. 


secrcforj 


ANATOMY 


43 


.  The  breasts  are  covered  with  very  delicate,  smooth,  -white  skin, 
excepting  for  the  areola;,  those  circular,  pigmented  areas  one  to 
four  inches  in  diameter,  which  surround  the  nipples.  The 
areolaB  are  darker  in  brunettes  than  in  blonds,  and  in  all  women 
grow  darker  during  pregnancy.  The  surface  of  the  nipples  and 
of  the  areolae  is  roughened  by  small,  shot-like  lumps  or  papillse 
known  as  the  tubercles  of  Montgomery.  This  roughness  becomes 
more  marked  during  pregnancy,  since  the  papillae  grow  larger 
and  sometimes  even  contain  milk. 


Fig.  15. — Front  view  of  breast  showing  areola,  tubercles  of  Montgomery 
and  orifices  of  milk  ducts. 

The  secretory  apparatus  of  the  breasts  is  divided  into  fifteen 
or  twenty  lobes,  these  in  turn  being  divided  into  clusters  of 
lobules.  The  lobules  in  turn  are  composed  of  tiny,  secreting  cells, 
called  acini,  in  which  the  milk  is  elaborated  from  the  blood.  The 
acini  are  minute  globules  lined  by  a  single  laj^er  of  cells  and  en- 
veloped by  a  very  delicate  membrane.  Tiny  ducts  carry  the 
milk  from  the  acini  to  the  main  duct  of  the  lobule,  around  which 
the  acini  cluster.  These  ducts  empty  the  milk  into  the  larger 
duct  of  the  lobe,  which  runs  straight  to  the  nipple  and  opens 
■upon  the  surface.  Just  before  reaching  the  surface,  each  of 
these  lactiferous  sinuses  expands  into  an  ampulla,  a  minute  res- 


44  OBSTETRICAL  NURSING 

ervoir  for  collecting  the  milk,  which  is  secreted  during  the 
periods  between  nursings. 

These  clusters  of  acini  uniting  to  form  lobules  with  tiny  ducts 
leading  into  the  main  duct  of  each  lobule,  closely  resemble  a 
bunch  of  grapes.  The  separate  grapes  correspond  to  the  acini, 
their  small  stems  correspond  to  the  tiny  ducts  of  the  glands  which 
lead  to  a  larger  one,  and  the  central  stem  of  the  grape  cluster,  to 
the  milk  duct  that  opens  upon  the  nipple. 

The  secretory  tissue  really  constitutes  a  small  part  of  the 
breasts  until  they  begin  to  function.  But  during  lactation  the 
acini  become  enormously  developed  and  enlarged.  After  lacta- 
tion ceases,  the  acini  assume  a  more  or  less  tubal  form,  many  of 
them  undergoing  atrophic  changes. 


CHAPTER  II 
PHYSIOLOGY 

Puberty  is  that  period  during  which  childhood  develops  into 
sexual  maturity,  and  the  individual  becomes  capable  of  repro- 
duction. 

The  age  at  which  puberty  occurs  varies  with  climate,  race, 
occupation  and  with  individuals  of  the  same  status.  But  the 
average  age  for  girls,  in  temperate  climates,  is  from  the  twelfth  to 
the  sixteenth  year;  for  boys  from  the  fourteenth  to  the  seven- 
teenth year.  Girls  in  southern  climates  sometimes  mature  as 
early  as  the  eighth  or  ninth  year,  while  in  colder  regions  puberty 
may  be  delayed  until  the  eighteenth  or  twentieth  year. 

At  this  time  there  are  many  physical  and  psychical  manifes- 
tations of  the  maturing  changes  in  the  internal  female  genera- 
tive organs.  The  undeveloped  girl  grows  rapidly  at  this  stage. 
Her  entire  body  rounds  out  and  assumes  a  more  graceful  con- 
tour ;  her  breasts  increase  in  size ;  her  hips  broaden ;  the  external 
genitalia  enlarge  and  hair  appears  over  the  pubis  and  on  other 
parts  of  the  body. 

As  this  physical  maturity  progresses,  there  is  a  dawning  sex 
consciousness  and  the  developing  girl  becomes  shy,  modest,  re- 
tiring and  introspective.  She  is  very  likely  to  he  emotional  and 
hysterical  and  to  display  a  lack  of  stability  and  nervous  control, 
which  are  not  in  accord  with  her  usual  temperament.  A  for- 
merly dependable  child  may  become  capricious,  erratic,  and  per- 
plexingly  inconsistent.  One  day  she  may  be  quite  her  normal, 
little-girl  self  and  the  next  show  inexplicably  mature  qualities. 
Or  she  may  display  a  bewildering  number  of  moods  and  fancies 
in  the  span  of  one  short  day. 

Too  much  cannot  be  said  of  the  importance  of  wise  supervi- 
sion and  guidance  of  the  girl's  physical,  mental  and  emotional 
life  at  this  critical,  emotional  period.     Many  gynecological,  ob- 

45 


46  OBSTETRICAL  NURSING 

stetrical  and  neurological  difficulties  in  her  later  life  may  be 
averted  by  her  observance  of  sane  rules  of  personal  hygiene. 

Vigorous  and  regular  out-of-door  exercise ;  a  simple,  nourish- 
ing and  well-balanced  diet;  adequate  sleep  in  a  well-ventilated 
room ;  regular  bathing,  and  correction  of  any  discoverable  physi- 
cal defects  are  the  essentials. 

But  of  equal,  if  not  greater,  importance  is  an  understanding 
and  sympathetic  oversight  of  the  girl's  mental  and  emotional 
life,  a  steadying  sort  of  comradeship. 

Her  extreme  sensitiveness  and  impressionability  should  be 
recognized  and  borne  in  mind,  and  every  effort  made  to  save  her 
from  strain  and  shock.  Her  nervous  forces  should  be  sedulously 
conserved  by  protecting  her  against  experiences  and  diversions 
which  would  be  unduly  stimulating  or  irritating.  Nor  should 
demands  be  made  upon  her  uncertain  nervous  endurance  which 
she  is  able  to  meet  only  by  great  strain,  if  at  all. 

It  is  important  to  her  future  poise  and  health  that  her  confi- 
dence be  courted,  and  when  it  is  won,  that  all  of  her  outpour- 
ings be  received  with  a  respect  and  seriousness  commensurate 
with  their  great  importance  to  her.  Ridicule,  and  even  unre- 
sponsiveness or  indifference  to  her  interests,  may,  and  often  do, 
result  in  a  hurtful  repression  of  one  form  or  another.  The  logi- 
cal consequence  of  such  repression  is  an  increasingly  damaging 
neurosis  later  on  in  her  life,  capable  of  greatly  impairing  her 
health,  happiness  and  usefulness. 

In  short,  all  phases  of  the  life  of  the  adolescent  girl  should 
be  made  as  wholesome,  tranquil  and  free  from  stress  and  strain 
as  is  humanly  possible. 

These  comments  upon  the  importance  of  mental  hygiene  at 
puberty  may  seem  irrelevant  to  a  discussion  of  obstetrical  nurs- 
ing. But  the  preparation  of  the  entire  female  organism  for  its 
supreme  function — that  of  child-bearing — is  of  concern  to  the 
obstetrical  nurse,  and  should  be  understood  by  her.  Moreover, 
every  nurse  is  inevitably  a  health  teacher,  either  by  precept  or 
example,  or  both.  An  awareness  on  her  part  of  the  maturing 
girl's  needs  will  fit  her  to  help  many  perplexed  mothers  whom 
she  meets  along  the  way  to  a  happy  solution  of  this  grave  and 
vexing  problem. 


PHYSIOLOGY 


47 


The  occurrence  of  puberty  marks  the  establishment  of  ovula- 
tion and  menstruation.  These  two  functions  are  usually  per- 
formed once  a  month,  ovulation  probably  occurring  about  mid- 
way during  the  inter-menstrual  period. 

Ovulation,  which  is  the  prime  function  of  the  ovary,  may  be 
defined  as  the  formation  and  development  of  the  ovum,  and  its 
expulsion,  when  mature,  from  tlie  ovary. 

The  formation  of  each  woman 's  full  quota  of  ova  is  probably 
complete  at  birth,  thoug:h  the  process  may  continue  until  about 
the  second  year.    At  this  time  it  is  variously  estimated  that  each 


nucleolus 


•membrdna 
ranulosa 


tleu^ 


Fig.  16. — Diagram  of  human  ovum. 

of  the  two  ovaries  contains  from  50,000  to  70,000  ova,  but  they 
remain  unmatured  until  puberty,  the  period  at  which  ovulation  is 
most  active. 

As  the  entire  complex  human  body  has  its  origin  in  this 
tiny  ovum,  its  course  of  development  is  of  momentous  importance 
to  us,  and  at  the  same  time  it  provides  a  tale  of  intense  interest. 

In  its  unmatured  state,  the  ovum,  termed  a  primordial  fol- 
licle, or  oocyte,  is  a  single  cell,  1/125  inch  in  diameter,  consist- 
ing of  clear  protoplasm,  the  vitelliis,  and  a  surrounding  vitelli7ie 
membrane  composed  of  small,  spindle-shaped  epithelial  cells. 
The  protoplasm  contains  a  fairly  large  nucleus,  or  germinal  ves^ 


48  OBSTETRICAL  NURSING 

icle,  within  which  lies  a  nucleolus  known  as  the  germinal  spot, 
{Fig.  16.) 

The  primordial  follicle  probably  lies  dormant  in  this  state 
until  puberty,  when  developmental  changes  take  place,  though  it 
is  the  belief  of  some  authorities  that  follicles  are  in  the  process  of 
development  from  birth  until  the  end  of  sexual  life,  though  none 
fully  mature  until  puberty. 

With  the  advent  of  puberty  the  cells  composing  the  vitelline 
membrane  change  in  character  and  proliferate  rapidly,  with  the 
result  that  the  ovum  is  surrounded  by  several  layers  of  epithelial 
cells.  Some  of  the  inner  cells  degenerate  and  liquify,  thus  sur- 
rounding the  ovum  with  fluid  which  is  contained  in  a  membrane 
of  vascular  connective  tissue,  the  theca  folliculi;  this  in  turn  is 
lined  with  epithelial  cells,  the  memhrana  granulosa.  This  struc- 
ture constitutes  a  Graafian  follicle,  named  for  Dr.  de  Graaf  who 
first  described  it,  and  in  the  course  of  its  maturation  is  pushed 
toward  the  surface  of  the  ovary,  where  it  presents  more  or  less 
the  appearance  of  a  clear  blister. 

At  one  point  in  the  enveloping  membrana  granulosa,  the 
cells  proliferate  into  a  mass  in  which  the  floating  ovum  becomes 
embedded.  This  mass  is  termed  the  discus  proligerus  and  the 
fluid  which  surrounds  it  is  the  liquor  folliculi. 

Usually  for  some  strange  reason,  one,  and  only  one,  ovum 
ripens  regularly  each  month  during  the  years  from  puberty  to 
the  menopause,  excepting  during  pregnancy,  when  this  function 
is  suspended.  Occasionally,  however,  several  ova  mature  at  once, 
a  condition  which  may  be  one  factor  in  the  development  of  twins. 
After  puberty  the  ovary  contains  ova  in  all  stages  of  develop- 
ment, from  the  primordial  follicle  to  the  Graafian  follicle  just  de- 
scribed. 

When  a  Graafian  follicle  containing  a  matured  ovum  reaches 
the  ovarian  surface,  its  membrane  becomes  thinner  and  finally 
ruptures  because  of  increased  tension  in  the  ovary,  due  to  certain 
circulatory  changes.  The  ovum  surrounded  by  the  discus  pro- 
ligerus is  thus  discharged  into  the  peritoneal  cavity  near  the 
fimbriated  end  of  the  tube.  Some  ova  enter  the  tube  and  others 
float  about  in  the  peritoneal  cavity,  finally  disintegrate  and  are 
lost. 


PHYSIOLOGY  49 

The  torn  envelope  of  the  follicle  which  remains  in  the  cortex 
of  the  ovary  becomes  filled  with  blood,  which  forms  into  a  clot. 
This  clot  is  first  surrounded,  and  then  invaded,  by  cells  contain- 
ing bright  yellow  pigment  called  lutein.  The  membrane  formed 
from  these  cells  compresses  the  clot  and  brings  about  other 
changes  which  speedily  transform  it  into  the  corpus  luteum. 

If  the  discharged  ovum  becomes  fertilized,  the  corpus  luteum 
remains  practically  unchanged  for  months  and  is  termed  the 
corpus  verum  or  corpus  luteum  of  pregnancy.  Its  secretion  is 
believed  to  influence  the  implantation  of  the  ovum  and  to  pro- 
mote the  woman's  general  well-being  during  the  period  of  ges- 
tation. It  continues  to  exist  throughout  pregnancy,  and  until 
after  delivery,  when  it  is  soon  absorbed  and  replaced  by  normal 
ovarian  tissue,  without  the  formation  of  scar  tissue. 

If  fertilization  does  not  occur,  the  body  in  the  ovarian  cortex, 
which  is  then  termed  the  corpus  luteum  of  menstruation,  or  false 
corpus,  undergoes  rapid  degenerative  changes  and  is  almost 
wholly  absorbed  within  a  few  weeks. 

By  means  of  this  rather  complicated  procedure  the  ovary  is 
saved  from  becoming  a  steadily  enlarging  mass  of  scar  tissue,  and 
consequently  devoid  of  reproductive  powers,  which  would  be  the 
ease  if  the  wound  made  by  the  rupturing  of  each  Graafian  fol- 
licle were  to  heal  by  the  usual  formation  of  cicatricial  tissue. 

Ordinarily  the  ovum  remains  unfertilized  and  is  propelled 
down  the  Fallopian  tube,  by  the  cilia  in  its  lining,  to  tlie  uterine 
cavity,  where  it  is  lost  in  the  uterine  secretions  and  ultimately 
carried  out  in  the  menstrual  flow. 

Each  time  that  an  ovum  matures,  however,  and  is  discharged 
from  the  ovary  the  lining  of  the  uterine  cavity  increases  in  vas- 
cularity and  becomes  thicker  and  more  velvety ;  a  condition  which 
facilitates  an  attachment  of  the  ovum  in  case  of  fertilization. 
This  preparation  of  the  endometrium  is  termed  "  pre-menstrual 
swelling,"  or  in  popular  language,  nest-building. 

Of  the  enormous  number  of  ova  existing  in  each  woman, 
relatively  few  mature  and  it  is  apparent  that  still  fewer  are 
fertilized,  since  each  impregnation  results  in  an  abortion,  a  pre- 
mature labor  or  a  full  term  child. 

Nature's  lavish  provision  of  something  more  than  100,000  ova 


50  OBSTETRICAL  NURSING 

for  each  woman,  who  uses  only  about  500  in  the  course  of  her 
life,  excites  no  little  wonder.  But  whatever  the  purpose  of  this 
enormous  supply,  its  existence  makes  possible  the  removal  of  all 
but  a  small  fragment  of  ovarian  tissue  in  cases  of  disease,  without 
interference  with  the  process  of  ovulation,  which  in  turn  permits 
reproduction. 

Menstruation,  which  is  the  evidence  of  sexual  maturity,  is  a 
monthly  hemorrhage  from  the  uterus  which  escapes  through  the 
vagina,  normally  recurring  throughout  the  entire  child-bearing 
period,  except  during  pregnancy  and  lactation.  The  duration  of 
this  child-bearing  period,  or  sexual  activity,  is  about  thirty  years 
and  continues  from  puberty  to  the  menopause. 

The  frequency  of  the  menstrual  periods  varies  in  different 
women  from  twenty-one  to  thirty  days,  but  the  normal  interval 
between  periods  is  twenty-eight  days,  which  corresponds  in  point 
of  time  to  the  menstrual  cycle.  Thus  it  is  usually  four  weeks,  or 
a  lunar  month,  from  the  beginning  of  one  period  to  the  beginning 
of  the  period  following,  making  thirteen  menstrual  periods  dur- 
ing each  calendar  year. 

Just  why  menstruation  occurs  about  every  twenty-eight  days 
is  not  known,  but  the  belief  is  that,  although  menstruation  is  in 
some  way  dependent  upon  ovulation,  its  periodicity  is  regulated 
by  the  corpus  luteum.  It  is  also  believed  that  the  corpus  luteum 
of  pregnancy  holds  menstruation  in  check  during  the  nine  months 
of  gestation. 

The  menstrual  cycle  is  divided  into  four  stages,  and  though 
there  is  not  entire  unanimity  of  opinion  concerning  the  changes 
which  take  place  during  these  four  stages,  the  preponderance  of 
evidence  is  in  favor  of  the  following  processes. 

The  first  or  constructive  stage  lasts  about  seven  days.  It  is 
during  this  stage  that  the  preparative  changes,  which  have 
been  described,  are  made  for  the  reception  of  the  matured  ovum. 
The  uterus  becomes  engorged  with  blood  and  is  somewhat  en- 
larged and  softened  as  a  result.  The  endometrium  grows  deep 
red,  thick  and  velvety,  partly  because  of  the  greatly  augmented 
blood  supply,  and  partly  because  of  an  actual  increase  of  con- 
nective tissue  in  its  structure.  There  is  also  an  increase  in  the 
size  and  activity  of  the  uterine  glands  and  in  the  amount  of  their 


PHYSIOLOGY  51 

secretions.  If  the  ovum  remains  unfertilized,  which  is  usually 
the  case,  it  does  not  attach  itself  to  this  elaborately  prepared 
lining,  but  passes  out  with  the  uterine  discharges,  and  all  of  this 
preparation  and  increased  vascularity  not  only  go  for  naught, 
but  must  be  undone. 

The  second  stag"e,  therefore,  which  lasts  about  five  days,  is 
the  destructive  stage,  during  which  the  newly  developed  tissues 
are  broken  down  and  the  menstrual  discharge  occurs.  During 
this  period  the  greatly  increased  secretions  of  the  uterine  glands 
mix  with  the  blood  that  oozes  from  the  engorged  endometrium 
and  with  the  disintegrated  uterine  tissues,  and  pour  from  the 
vagina  as  the  menstrual  flow. 

The  third,  or  reparative  stage,  which  follows,  occupies  about 
three  days.  During  this  stage  the  destroyed  uterine  tissues  are 
regenerated  by  new  growth  from  the  deeper,  uninjured  tissues, 
and  the  entire  organ  returns  to  its  normal  state. 

The  fourth,  or  quiescent  stage,  now  follows,  the  damage  hav- 
ing been  repaired,  and  lasts  twelve  or  fourteen  days.  This  is  the 
time  remaining  before  Nature  with  unwearying  patience  begins 
all  over  again  to  prepare  for  the  reception  and  attachment  of  the 
next  matured  ovum,  in  case  of  its  possible  fertilization. 

It  will  be  seen  that  tlie  duration  of  the  menstrual  period, 
which  is  coincident  with  the  destructive  stage  of  the  menstrual 
cycle,  is  about  five  days,  but  it  is  entirely  within  normal  bounds 
if  it  varies  in  length  from  two  to  seven  days. 

The  discharge  is  usually  scant  at  the  beginning  of  the  period, 
increasing  in  amount  until  about  the  third  day,  after  which  it 
diminishes  steadily  until  its  cessation.  The  normal  odor  of  this 
discharge,  consisting  as  it  does  of  blood  and  uterine  secretions, 
has  been  likened  to  that  of  marigolds. 

The  average  amount  of  blood  lost  is  from  six  to  ten  ounces, 
but  it  varies  greatly  among  women  who  are  otherwise  normal 
and  in  good  health.  Some  women  regularly  lose  what  seems  to 
be  an  alarming  (juantity  of  blood  at  each  period  without  suffer- 
ing any  apparent  ill  effect.  Others  lose  so  little  that  they  are 
scarcely  aware  of  their  menses. 

As  a  rule  the  menstrual  flow  is  more  profuse  among  women 
in  warm  climates  than  in  cold  regions.    English  women,  for  ex- 


52  OBSTETRICAL  NURSING 

ample,  frequently  menstruate  profusely  while  in  India,  and  upon 
their  return  to  England  note  a  marked  decrease  in  the  amount 
of  the  discharge.  The  same  is  often  true  of  American  women 
who  move  from  Southern  to  Northern  states,  while  removal  from 
a  low  to  a  high  altitude  usually  results  in  a  more  profuse  flow. 

The  quantity  of  the  menstrual  discharge  is  affected  also  by 
diet,  living  conditions  and  by  any  form  of  mental  or  physical 
excitement  or  stimulation. 

Accordingly,  the  highly  strung,  richly  nourished  women  liv- 
ing in  luxurious  circumstances  are  likely  to  menstruate  more 
freely  than  those  less  favored  who  are  overworked  and  poorly 
nourished. 

A  shock  or  great  grief,  or  any  great  emotional  experience ;  a 
sea  voyage  or  a  long  railroad  journey  may  bring  on  a  period  be- 
fore it  is  due,  while  the  regularity  of  the  periods  may  be  much 
disturbed,  temporarily,  by  a  marked  change  of  climate  or  alti- 
tude, a  serious  illness  or  a  decided  change  in  one's  daily  regime. 

The  function  may  be  entirely  suspended  for  several  months 
or  a  year  in  women  who  suddenly  take  up  hard  work  or  violent 
exercise,  and  persist  with  it  regularly.  In  such  cases  the  periods 
gradually  recur  and  finally  become  normal  and  regular. 

The  menstrual  period  is  frequently  attended  by  evidences  of 
marked  mental  and  physical  disturbances.  While  many  women 
are  fortunate  enough  to  suffer  little  or  no  inconvenience  during 
menstruation,  the  vast  majority  are  more  or  less  wretched  and 
miserable  at  this  time,  although  in  good  health  in  all  other  re- 
spects. Many  are  tired,  have  less  endurance  than  usual  and  are 
likely  to  take  cold  easily.  Headaches  with  a  sense  of  fullness, 
dizziness,  and  heaviness  are  common  accompaniments.  Back- 
ache is  a  frequent  source  of  discomfort,  while  abdominal  pain, 
varying  from  an  uncomfortable  sense  of  dragging  heaviness  to 
almost  unendurable  agony,  is  the  rule  rather  than  the  exception. 
And  there  may  be  pain  in  the  hips  and  thighs  as  well. 

This  state  of  wretchedness  is  sometimes  increased  by  a  loss 
of  appetite,  nausea  and  even  vomiting.  At  the  same  time  there 
are  changes  in  the  breasts  which  are  much  the  same  as,  though 
slighter  than,  those  occurring  during  pregnancy.  They  are 
firmer,  may  be  somewhat  increased  in  size,  and  many  women 


PHYSIOLOGY  53 

experience  a  burning,  tingling  sensation,  soreness  and  even  pain. 
The  nipples  are  turgid  and  prominent  and  the  pigmented  areas 
grow  darker  for  the  time  being. 

The  skin  over  the  rest  of  the  body  sometimes  changes  in  ap- 
pearance and  pimples  are  common ;  some  women  are  pale  and 
others  are  flushed  during  their  periods. 

These  physical  disturbances  accompanying  menstruation 
vary  so  widely  in  different  women,  and  in  the  same  women  at 
different  times  and  under  different  conditions,  that  it  is  not  pos- 
sible to  draw  a  classical  picture  of  the  condition.  But  all  of  the 
symptoms  above  described  will  persist  wath  more  or  less  severity 
throughout  the  entire  menstrual  life  of  one  woman,  while  per- 
haps only  one  or  tw^o  of  them  will  occasionally  disturb  another. 
Whatever  discomfort  there  may  be  usually  begins  from  one  day 
to  a  week  before  the  discharge  appears;  is  at  its  height  during 
the  following  day  and  from  that  time  subsides  steadily,  until  the 
normally  comfortable  state  is  regained.  In  fact,  many  women 
feel  better  at  the  end  of  their  periods  and  during  the  days 
immediately  following  than  at  any  other  time  during  the 
cycle. 

Heat  applied  to  the  abdomen  and  lumbar  region  during  the 
uncomfortable  days;  hot  baths,  rest  and  quiet,  will  usually  give 
great  relief,  as  might  be  expected  when  there  is  local  congestion 
and  general  nervous  irritability.  In  this  connection,  it  is  worth 
mentioning  that  the  discomfort  of  many  w'omen  is  needlessly 
increased  by  their  heeding  the  widespread  but  fallacious  belief 
that  general  bathing  during  menstruation  is  injurious.  While 
cold  plunges  and  cold  showers  are  not  recommended,  certainly 
warm  baths  are  innocuous  and  immensely  satisfying. 

In  addition  to  the  physical  discomfort  which  is  coincident 
with  menstruation,  and  quite  as  common,  are  the  evidences  of 
mental  and  nervous  instability.  These  often  show  themselves  in 
the  form  of  unwarranted  irritability,  and  in  a  lack  of  poise  and 
self-control.  Drowsiness  and  mental  sluggishness  are  not  un- 
common, and  many  otherwise  cheerful  women  are  almost  over- 
whelmed by  depression  during  menstruation. 

All  of  these  departures  from  what  we  are  accustomed  to  re- 
gard as  the  normal,  or  average,  mental  and  physical  state  of 


54  OBSTETRICAL  NURSING 

women  are  very  baffling,  as  they  may  persist  after  every  dis- 
coverable defect  lias  been  corrected. 

But  aside  from  all  other  considerations  it  is  of  obstetrical  im- 
portance for  the  sufferer  to  ascertain  the  cause  of  her  discomfort 
if  possible.  For  example,  a  misplacement  of  the  uterus  is  a 
frequent  cause  of  dysmenorrhea  and,  if  it  remains  uncorrected, 
may  make  conception  impossible;  or  if  conception  perchance 
does  take  place,  the  malposition  of  the  uterus  may  later  be  the 
cause  of  an  interrupted  pregnancy. 

Endometritis  is  another  cause  of  menstrual  difficulty  and  if 
allowed  to  persist  may  be  one  factor  in  the  causation  of  abnormal- 
ities in  the  attachment  of  the  placenta. 

There  is  evidently  an  intimate  relation  between  the  process 
of  menstruation  and  the  functions  of  the  ductless  glands  through- 
out the  body ;  a  relation  which  is  far  from  being  understood. 

For  example,  the  administration  of  various  preparations  of 
ductless  glands  for  maladies  which  are  apparently  unrelated  to 
menstruation,  results  not  alone  in  an  improvement  of  the  condi- 
tion treated,  but  frequently  in  much  more  comfortable  men- 
strual periods,  as  well. 

It  should  be  borne  in  mind,  also,  that  the  influence  exerted 
by  a  woman's  mental,  or  psychic,  state  upon  her  menstrual  pe- 
riods is  so  apparent  that  it  is  being  given  increasingly  serious 
recognition.  It  is  frequently  observed  that  patients  who  are 
under  treatment  for  nervous  and  mental  disorders,  who  are  also 
sufferers  from  painful  menstruation,  grow  more  comfortable  dur- 
ing their  periods  as  their  neurosis  improves. 

We  have  constantly  before  us  examples  of  painful  menstrua- 
tion being  relieved  coincidently  with  an  improved  mental  state 
among  women  situated  at  the  two  extremes  of  the  social  and 
financial  scale.  Indolent,  self-centred  and  unoccupied  women 
at  one  end  often  become  excessively  nervous  and  irritable,  and 
suffer  great  pain  w^ith  each  period,  while  the  overworked,  har- 
assed, poverty-stricken  women  at  the  other  extreme  have  simi- 
larly trying  menstrual  experiences.  When  the  self-indulgent 
sister  can  be  persuaded  to  engage  in  some  form  of  physical  activ- 
ity and  to  interest  herself  in  some  work  which  requires  mental 
effort,  and  which  perhaps  makes  an  emotional  appeal  as  well,  she 


PHYSIOLOGY  55 

frequently  finds  that  her  menstrual  difficulties  become  less  trou- 
blesome. 

In  the  case  of  the  woman  in  poorer  circumstances,  an  im- 
provement in  her  mode  of  living  which  approaches  the  normal, 
and  a  relief  from  undue  stress  and  anxiety,  will  very  often  be 
followed  by  more  comfortable  menstruation. 

A  recognition  of  these  rather  intangible  facts  is  of  conse- 
quence to  the  nurse,  as  it  deepens  her  appreciation  of  the  neces- 
sity for  nursing  her  patient  as  a  complete  entity,  mentally,  physi- 
cally, spiritually  and  emotionally.  We  are  insistently  reminded 
at  every  turn  that  no  one  part  of  the  patient,  no  one  aspect  of 
her  condition  can  be  separately  considered  and  the  remainder 
overlooked. 

The  patient  can  be  nursed  quite  satisfactorily  only  when  she 
is  nursed  completely. 

Relation  Between  Ovulation  and  Menstruation. — Menstrua- 
tion and  ovulation  are  apparently  associated  and  interdependent, 
but  the  exact  relation  between  the  two  is  still  obscure  and  puz- 
zling. It  is  generally  accepted  that  complete  removal  of  the 
ovaries  stops  ovulation  and  is  followed  by  a  cessation  of  men- 
struation, and  yet  cases  have  been  recorded  which  suggest  that 
these  two  functions  are  not  invariably  correlative. 

Evidence  of  this  possible  independence  is  that,  although  preg- 
nancy must  be  preceded  by  ovulation,  it  has  occurred  before 
puberty  or  after  the  menopause.  And  not  infrequently  preg- 
nancy occurs  during  lactation,  a  period  when  the  menstrual 
function  is  usually  suspended. 

It  has  been  claimed  by  some  observers  that  menstruation  has 
occurred  after  the  complete  removal  of  both  ovaries,  which 
would,  of  course,  preclude  the  possibility  of  further  ovulation. 
It  is  possible,  however,  that  in  such  cases  either  the  ovaries  were 
not  entirely  removed,  though  believed  to  be,  or  that  an  acces- 
sory ovary  existed,  since  a  very  small  fragment  of  ovarian  tissue 
will  permit  the  occurrence  of  ovulation. 

As  to  their  chronological  relation,  information  available  at 
present  suggests  that  ovulation  occurs  about  ten  or  twelve  days 
after  the  close  of  the  preceding  period,  and  that  the  corpus  lu- 


56  OBSTETRICAL  NURSING 

teum  formed  at  the  site  of  the  rupture  reaches  its  highest  devel- 
opment some  ten  or  twelve  da.vs  later,  and  that  the  degenerative 
changes  in  the  corpus  luteum,  in  ease  of  non-fertilization  of  the 
ovum,  give  rise  to  menstruation. 

Modifications  of  Menstruation.  Dysmenorrhea  is  painful 
menstruation. 

Menorrhagia  is  an  abnormally  copious  menstrual  flow. 

Amenorrhea  is  irregularity  or,  to  be  exact,  suppression  of 
the  menses.  The  suppression  may  be  due  to  an  obliteration  of 
the  neck  of  the  uterus,  or  to  an  occlusion  of  the  vaginal  opening. 

Vicarious  menstruation  is  an  escape  of  blood  from  other 
parts  of  the  body  coincident  with  menstruation.  Blood  may  ooze 
through  the  skin  covering  the  breasts ;  also  from  hemorrhoids  or 
from  the  surface  of  ulcers.  Or  there  may  be  nose-bleeding,  vom- 
iting of  blood  or  pulmonary  hemorrhage,  particularly  among 
tuberculous  patients.  Vicarious  menstruation  usually  occurs 
among  nervous,  high-strung  women  and  may  be  regarded  as  an 
evidence  of  ill  health.  The  amount  of  blood  lost  in  this  way  is 
much  less  than  the  amount  of  the  menstrual  flow. 

The  menopause,  also  termed  the  climacteric  and  the  change  of 
of  life,  marks  the  permanent  cessation  of  menstruation  and  of 
sexual  activity.  It  occurs  ordinarily  between  the  ages  of  forty 
and  fifty;  the  majority  of  women  stop  menstruating  at  their 
forty-sixth  year.  The  menopause  has  occurred  as  early  as  the 
twenty-fifth  year,  and  as  late  as  the  eightieth  or  ninetieth  year. 
But  such  cases  are,  of  course,  extremely  rare  and  their  infrequent 
occurrence  is  of  interest  rather  than  of  importance  in  an  effort 
to  ascertain  the  general  average. 

As  the  child-bearing  period  is  normally  about  thirty  years  in 
duration,  the  prevailing  belief  is  that  the  menopause  comes  ear- 
lier to  women  who  began  menstruating  early,  than  to  those  who 
did  not  reach  puberty  until  later.  Some  authorities  contend, 
however,  that  early  menstruation  indicates  extreme  vitality,  and 
that  this  vitality  tends  to  prolong  the  child-bearing  period.  Ac- 
cording to  this  theory,  then,  the  menopause  w'ould  come  late  to 
those  who  matured  early  and  vice-versa. 

As  the  menopause  approaches,  menstruation  occurs  irregu- 
larly ;  the  discharge  sometimes  increases  slightly  but  usually  dim- 


PHYSIOLOGY  57 

inishes  in  amount  and  finally  disappears  altogether,  while  the 
generative  organs  all  undergo  atrophic  changes. 

Bearing  iji  mind  the  disquieting  effect  of  adolescence,  and  of 
ovulation,  upon  the  general  nervous,  mental  and  physical  state, 
we  may  reasonably  expect  that  a  complete  cessation  of  the  ova- 
rian function  would  be  attended  by  more  or  less  disturbance  of 
the  general  well-being. 

It  is  true  that  very  many  women  suffer  a  certain  amount  of 
nervous  instability  at  the  metiopause;  they  tire  easily;  have  "hot 
flashes"  and  possibly  headaches.  But  under  ordinary  conditions 
the  discomfort  is  not  great,  and  after  the  function  has  entirely 
ceased  and  they  become  physiologically  adjusted  to  the  new 
order  of  things,  these  women  often  enjoy  better  health  than  ever 
before. 

Unfortunately  wide  currency  has  been  given  to  exaggerations 
concerning  the  symptoms  of  the  menopause.  The  result  is  that 
serious  organic  diseases  which  are  in  no  way  related  to  the  cli- 
macteric are,  not  infrequently  attributed  to  it.  For  this  reason 
excessive  bleeding,  heart  symptoms  and  what  not  are  all  too  often 
accepted  as  a  matter  of  course,  and  accordingly  neglected  until 
the  patient  is  beyond  medical  aid.  This  is  particularly  and  trag- 
ically true  of  cancer  of  the  uterus. 

It  is  a  wise  precaution,  therefore,  to  regard  with  apprehen- 
sion an  increase  in  the  amount  of  the  menstrual  flow  of  any  wo- 
man past  thirty,  and  not  to  accept  it  as  a  normal  forerunner  of 
the  menopause. 


In  the  dark  womb  where  I  began 
My  mother's  life  made  me  a  man. 
Through  all  the  months  of  human  birth 
Her  beauty  fed  my  common  earth. 

— John  Masefield. 


PART  II 

The  Development  op  the  Baby 

CHAPTER  III.  DEVELOPMENT  OF  THE  QTVUM,  EMBRYO,  FETUS, 
PLACENTA,  CORD  AND  MEMBRANES.  The  Ovum.  The  Sper- 
matazoon.  Fertilization.  Heredity.  Sex-determination.  Most 
Favorable  Age  for  Motherhood.  The  Morula.  Growth  in  the  Uterus. 
The  Decidua.  Ectoderm.  Mesoderm.  Entoderm.  The  Chorion  and 
Placenta.  The  Amnion.  The  Umbilical  Cord.  The  Fetus.  Growth 
by  Months.  Factors  Influencing  the  Size  of  Child.  Multiple  Preg- 
nancy.    Extra-uterine   Pregnancy. 

CHAPTER  IV.  GROWTH  AND  PHYSIOLOGY  OF  THE  FETUS.  Cir- 
culation. Kidneys.  Bowels.  Head.  Fontanelles.  Occipital  Meas- 
urements. 

CHAPTER  V.  SIGNS,  SYMPTOMS,  AND  PHYSIOLOGY  OF  PREG- 
NANCY. Duration  of  Pregnancy.  Date  of  Labor.  Signs  of  Preg- 
nancy: Presumptive,  Probable,  and  Positive.  Physiological  Changes 
in  the  Maternal  Organism:  Uterus.  Cervix.  Vagina.  Tubes  and 
Ovaries.  Abdomen.  Umbilicus.  Breasts.  Cardio-Vascular  System. 
Respiratory  Organs.  Digestive  Tract.  Urinary  Apparatus.  Bony 
Structures.  Skin.  Carriage.  Temperature.  Mental  and  Emotional 
Changes.    Ductless  Glands. 


CHAPTER  III 

THE  DEVELOPMENT  OF  THE  OVUM,  EMBRYO,  FETUS, 
PLACENTA,  CORD  AND  MEMBRANES 

As  we  learned  in  the  last  chapter,  some  of  the  ova  which  are 
discharged  into  the  peritoneal  cavity  enter  the  fimbriated  end 
of  the  tube,  while  very  many  others  perish.  As  a  rule  an  ovum 
enters  the  tubal  opening  adjacent  to  the  ovary  from  which  it 
has  been  discharged,  but  it  is  possible  for  this  tiny  cell  to  travel 
across  the  body  and  enter  the  tube  on  the  opposite  side. 

This  migration  of  the  ovum,  as  it  is  termed,  has  been  dem- 
onstrated in  cases  in  which  pregnancy  has  followed  removal  of 
the  ovary  on  one  side  and  the  tube  on  the  other. 

There  are  various  theories  as  to  how  and  why  an  occasional 
migrating  ovum,  floating  around  in  a  relatively  large  cavity,  ever 
enters  the  tubal  opening,  which,  after 
all,  is  not  large.  The  most  widely 
accepted  belief  is  that  the  motion  of 
the  cilia  lining  the  tubes  creates  a 
suction  which  draws  the  microscop- 
ical cell  into  the  opening,  the  same 
cilia  being  the  means  by  which  the 
ovum  is  later  propelled  downward 
through  the  tube  to  the  uterus. 

This  journey  of  the  ovum  through 
the  tube  is  of  enormous  consequence. 
During  its  course  occur  the  events 
which  decide  whether  the  ovum  shall, 
like  most  of  its  fellows,  be  simply 
swept  along  to  no  end  and  lost,  or  whether  by  chance  it  is  to 
receive  the  mysterious  impulse  which  begins  the  development  of 
a  new  human  being. 

The  amazing  power  which  enables  this  cell  to  reproduce  itself, 
and  to  develop  with  unbelievable  complexity,  is  acquired  some- 

61 


Fig.  17. — Diagram  of 
spermatazoa,  the  male  cells 
of  germination. 


62  OBSTETRICAL  NURSING 

where  in  the  tube  by  meeting  and  fusing  with  a  spermatozoon, 
the  germinal  cell  of  the  male.     (Fig.  17.) 

The  spermatozoa  look  very  much  like  microscopic  tadpoles, 
with  their  flat,  oval  heads,  tapering  bodies  and  long  tails.  As 
these  tails  serve  somewhat  as  propellers,  the  male  cells  are  capa- 
ble of  very  rapid  motion.  But  in  spite  of  their  strange  appear- 
ance, they  are  cells  after  all,  and  resemble  the  female  cells  in 
that  each  one  contains  a  nucleus,  or  germinal  spot. 

An  almost  inconceivably  large  number  of  spermatozoa,  float- 
ing in  the  seminal  fluid,  is  deposited  in  the  vagina  at  the  time  of 
intercourse.  Nature  evidently  supplies  the  male  and  female  cells 
with  equal  lavishness,  in  order  to  provide  for  the  large  number 
of  both  kinds  which  must  inevitably  be  lost,  and  still  have  enough 
survive  to  accomplish  the  high  purpose  of  their  creation.  A  very 
considerable  number  of  spermatozoa  enter  the  uterus,  and  are 
enabled  through  their  powers  of  motility,  to  travel  up  into  the 
tubes,  in  spite  of  the  downward  current  created  by  the  cilia. 
And  in  the  tube,  usually  in  the  upper  end,  they  meet  a  recently 
matured  and  discharged  ovum  which  is  being  swept  downward, 
and  are  attracted  to  it  somewhat  as  bits  of  metal  are  drawn  to 
a  magnet.  Although  the  ovum  which  is  destined  to  be  fertilized 
is  surrounded  by  several  spermatozoa,  only  one  actually  enters 
and  fuses  with  it. 

This  fusion  is  termed  impregnation,  fertilization,  or,  in  lay 
parlance,  conception,  and  the  instant  at  which  it  occurs  marks 
the  beginning  of  pregnancy.  The  establishment  of  this  fact  is 
of  no  little  importance,  since  it  does  away  with  any  possible  con- 
troversy concerning  the  time  at  which  a  new  life  begins.  The 
origin  of  the  child  is  exactly  coincident  with  the  fusion  of  the 
male  and  female  germinal  cells. 

And  furthermore,  the  sex  of  the  child  and  any  inherited  traits 
and  characteristics  are  also  established  at  this  decisive  instant. 
No  amount  of  dieting,  exercise  nor  mental  effort  on  the  part  of 
the  expectant  mother  can  alter  or  influence  them  in  the  smallest 
degree,  for  the  father  has  made  his  complete  contribution  toward 
the  creation  of  the  new  being,  and  after  this  event  the  mother 
provides  nourishment  only. 

All  told,  probably  more  than  five  hundred  theories  have  been 


DEVELOPMENT  OP  THE  OVUM  AND  EMBRYO   63 

advanced  to  explain  what  it  is  tliat  decides  of  which  sex  the  forth- 
coming child  will  be. 

In  1907  Dr.  Schenck  attracted  world  wide  attention  by  an- 
nouncing his  belief  that  either  sex  could  be  i)i'oduced  in  the  ex- 
pected child  through  the  simple  expedient  of  I'cgulatiiig  the 
mother's  diet.  Liberal  feeding  would  result  in  boys,  the  sturdier 
sex,  and  frugality  in  girls,  the  smaller,  frailer  type  of  baby. 
But  as  the  results  of  applying  Schenck 's  theory  have  scarcely 
borne  out  his  claims,  it  is  given  but  scant  attention  to-day. 

The  present  belief  regarding  the  causation  of  sex  is  that  al- 
though there  is  but  one  kind  of  ovum,  there  are  two  kinds  of 
spermatozoa,  one  capable  of  producing  a  male,  and  the  other  a 
female  child.  These  two  kinds  are  evidently  deposited  in  the 
vagina  in  about  equal  numbers,  and  the  sex-determining  form 
that  fertilizes  any  one  ovum  is  a  matter  of  the  merest  chance. 
Statistics  show,  however,  that  more  male  than  female  babies 
are  born,  the  usual  proportion  being  about  105  boys  to  100  girls 
among  those  that  reach  full  term.  Among  abortions  and  prema- 
ture births  there  is  also  a  larger  number  of  boys  than  girls,  and 
in  elderly  primiparae  the  ratio  increases  to  about  130  boys  to  100 
girls.  But  as  more  boys  die  in  infancy  than  girls,  the  two  sexes 
about  even  up  in  the  number  of  those  living  to  adult  age. 

Apparently,  then,  there  is  some  factor  operating  slightly  in 
favor  of  the  purposeful  activities  of  the  male-producing  sperma- 
tozoa. But  so  far  no  accurate  means  has  ever  been  found  where- 
by it  was  possible  to  influence  the  development  or  discover  the 
sex  of  a  child  before  its  birth. 

There  is  a  wide  difference  of  opinion  concerning  the  time  of 
the  month  when  fertilization  is  most  likely  to  occur.  Observa- 
tions made  upon  the  wives  of  sailors  and  under  a  variety  of  con- 
ditions suggest  that  the  most  favorable  period  is  just  before  or 
just  after  menstruation  which  represents  the  second  stage  of  the 
menstrual  cycle. 

Dr.  Williams  believes,  however,  that  fertilization  is  most  likely 
to  occur  about  midway  during  the  intermenstrual  period. 
But  since  it  is  probable  that  spermatozoa  are  constantly  present 
in  the  tubes  of  women  who  are  exposed  to  the  possibility  of  be- 


64  OBSTETKICAL  NURSING 

coming  pregnant,  it  is  difficult  to  do  more  than  speculate  about 
the  time  of  the  month  at  which  fertility  is  greatest. 

Another  moot  question  relates  to  the  age  of  the  woman  at 
which  it  is  most  desirable  that  the  first  child  shall  be  born.  Re- 
cent observations  made  by  Dr.  John  W.  Harris  upon  a  large  num- 
ber of  pregnancies  occurring  in  very  young  girls  indicates  that 
from  a  standpoint  which  considers  solely  the  physical  welfare 
of  the  mother  and  her  infant,  sixteen  years  is  the  most  satisfac- 
tory age  at  which  to  bear  the  first  child. 

However,  when  motherhood  is  considered  from  all  stand- 
points, social,  ethical,  spiritual  as  well  as  physical,  the  concensus 
of  opinion  seems  to  be  that  the  twenty-third  year  is  the  most 
favorable  age  for  motherhood  to  begin.  Children  have  been 
born  to  little  girls  nine  years  old  and  to  women  of  sixty-two,  but 
the  extremes  of  the  reproductive  years  are  not  favorable  periods 
for  child-bearing. 

As  soon  as  a  spermatozoon  enters  an  ovum,  it  disappears  and 
is  completely  absorbed,  and,  as  the  ovum  in  turn  is  instantly 
possessed  of  new  powers,  the  result  of  this  union  is  a  cell  which 
was  previously  non-existent. 

This  new  cell  is  not  only  capable  of  reproduction  by  means 
of  segmentation  or  cell  division,  but  in  the  course  of  its  sub- 
division and  proliferation,  it  forms  groups  of  cells  which  develop 
into  tissues  and  structures  widely  different  from  each  other. 
The  entire  complex  human  body,  in  addition  to  the  placenta, 
cord,  and  membranes,  arises  from  the  single,  extraordinary  cell. 

It  first  divides  into  two ;  these  two  divide  into  four ;  the  four 
into  eight  and  thus  the  process  of  division  and  sub-division  con- 
tinues until  a  solid  mass  is  formed,  shaped  something  like  a  mul- 
berry and  called  the  morula.     (Fig.  18.) 

While  these  developmental  changes  are  taking  place,  the 
morula  is  being  carried  down  the  tube  toward  the  uterus,  by 
the  swee|)ing  motion  of  the  ciliated  membrane.  The  time  con- 
sumed by  this  journey  has  not  been  definitely  ascertained  and 
though  possibly  it  may  be  made  in  a  few  hours,  it  probably 
takes  from  five  days  to  a  week.  Since  the  embryo  is  constantly 
moving  during  this  time,  it  quite  evidently  has  no  attachment 
to  the  mother  and  cannot,  therefore,  derive  any  great  amount 


( 


DEVELOPMENT  OF  THE  OVUM  AND  EMBRYO   65 

of  nourishment  directly  from  her.  The  growth  and  develop- 
ment to  this  point,  then,  must  be  due  cliiefly  to  inherent  powers 
within  the  mass  of  cells  itself. 

In  all  probability,  the  embryo  is  still  in  the  morula  stage  and 
is  about  the  size  of  the  head  of  a  pin  when  it  reaches  the  uterus, 
where  it  finds  that  the  endometrium  has  been  prepared  for  its 
reception  by  the  premenstrual  swelling.  The  mucosa  has  grown 
thicker,  more  velvety  and  vascular,  and  its  glands  have  increased 
in  number  and  activity.  The  columnar  epithelium  of  the  endo- 
metrium is  replaced  by  a  thick  layer  of  large,  vacuolated  cells, 


FiVst     stages       «{        «ell      di'vi'sior^ 


Morula      stage's 

Dlasioderirnic     vesicle. 
FiQ.  18. — Diagram  of  segmenting  rabbit's  ovum. 


called  decidual  cells,  and  the  uterine  lining  from  now  on  is 
termed  the  decidua  gravidatis.  While  the  normal  uterine  mucosa 
is  thin,  averaging  from  1  to  3  millimetres  (0.039  to  0.117  inch) 
in  thickness,  it  increases  to  a  thickness  of  about  1  centimetre 
(%  inch)  during  pregnancy. 

The  point  at  which  the  embryo  attaches  itself  to  this  spongy 
membrane  is  entirely  a  matter  of  chance.  It  usually  rests  some- 
where in  the  upper  part  of  the  uterine  cavity,  promptly  de. 
stroys  the  minute  underlying  area  of  tissue  by  digestive  action 
and  burrows  into  the  decidua.  As  the  margins  of  the  opening 
thus  made  meet  and  fuse  above  the  ovum,  it  is  completely  in- 


66  OBSTETRICAL  NURSING 

capsulated  in  a  cavity  of  its  own  that  has  no  connection  with 
the  uterine  cavity.     (Fig.  19.) 

After  this  occurrence  the  decidua  consists  of  three  portions: 
the  hypertrophied  membrane  which  lines  the  uterus  as  a  whole, 
called  the  decidua  vera,  which  atrophies  during  the  latter  part 
of  pregnancy  and  is  also  thrown  off  in  part  with  the  membranes 
during  labor,  and  later  in  the  uterine  discharges;  the  decidua 
hasalis,  or  the  decidua  serotina,  is  that  portion  lying  directly 
beneath  the  embryo  which  later  enters  into  the  formation  of  the 


BlcLduQ     GOpU 

ai-i=.                                       PoLnt 

j\  ent 

ronce 

^..    .^r  .«iiiu-i  *  Aw 

'f^:^f^::'-^\ 

'-"'.-^^    .4.x '"*■'•"-    " 

*•  *« 

■^ 

'  v;!^"" 

Huclewt. 

Ovurn — 

t  ^ « » 

Biotdua 

bo  so 

IS 

Fig.  19. — Ovum  about  13  days  old,  embedded  in  the  decidua.     (The  Bryce- 
Teacher  ovum  from  Human  Embryology  by  Keibel  and  Mall.) 

placenta ;  and  the  decidua  reflexa,  which  surrounds  and  covers 
the  buried  embryo,  consists  of  the  developed  and  fused  margins 
of  the  pit  in  the  mucosa,  that  have  grown  over  the  embryo. 

As  the  cellular  activity  continues  within  the  morula,  fluid 
appears  in  the  centre  with  the  result  that  the  cells  are  rear- 
ranged and  pushed  toward  the  periphery,  thus  forming  a  sac. 
At  this  stage  the  embryo  is  called  the  blastodermic  vesicle. 

At  one  point  on  the  inner  surface  of  this  vesicle  the  cells 
proliferate  and  form  a  mass  which  is  sometimes  called  the  in- 
ternal cell  mass,  or  embryonic  area,  and  the  single  layer  of 
cells  comprising  the  remainder  of  the  vesicular  wall,  the  primi- 


DEVELOPMENT  OF  THE  OVUM  AND  EMBRYO   67 

tive  chorion.  The  cells  in  the  mass  are  at  first  disposed  in  layers, 
the  outer  layer  being  termed  the  ectoderm;  the  inner  layer  the 
entoderm,  while  a  third  layer  which  appears  a  little  later  is 
called  the  mesoderm. 

Although  these  three  primitive  layers  of  cells  have  all  arisen 
from  the  single  cell  formed  by  the  fused  spermatozoon  and  ovum, 
they  are  even  now  very  different  in  character.  The  differences 
steadily  increase  until  finally  all  of  the  complex  fetal  organs 
and  tissues,  the  membranes,  cord  and  placenta,  result  from  their 
further  specialization  and  development,  as  follows: 

From  the  ectoderm  arises  the  skin  with  its  appendages,  and 
the  salivary  and  mammary  glands;  the  nasal  passages,  upper 
part  of  the  pharynx  and  the  anus;  the  crystalline  lens,  the  ex- 
ternal ear,  the  entire  nervous  system,  the  sense  organs  and,  in 
part,  the  fetal  membranes. 

From  the  mesoderm  are  derived  the  urinary  and  reproduc- 
tive organs;  the  muscles,  bones,  and  connective  tissues  and  the 
circulatory  systems. 

From  the  entoderm  are  developed  the  alimentary  canal,  the 
thymus,  thyroid,  liver,  lungs,  pancreas,  bladder  and  the  various 
small  glands  and  tubules. 

It  was  formerly  believed  that  the  human  being  existed  in 
miniature  in  the  first  cell  and  that  its  development  during  preg- 
nancy was  entirely  a  matter  of  increase  in  size.  But  the  micro- 
scope has  disproved  this,  and  we  now  know  that  embryonic  de- 
velopment comprises  both  growth  and  evolution. 

Much  of  the  information  accepted  to-day  is,  of  course,  specu- 
lative, having  been  deduced  from  observations  made  upon  the 
reproductive  processes  of  lower  mammals,  since  the  youngest 
human  ovum  which  has  been  discovered  and  examined  was  prob- 
ably two  weeks  old.  But  the  evidence  points  qnite  convinc- 
ingly to  the  belief  that  the  early  stages  of  development  consist 
of  proliferation  of  and  alterations  in  the  kinds  of  cells,  their 
arrangement  into  groups,  and  a  differentiation  of  the  functional 
activity  of  these  groups  of  cells  before  the  mass  assumes  human 
form  and  develops  organs. 

As  to  terminology,  some  authorities  call  this  mass  the  embryo 
during  this  stage  of  grouping  and  differentiation,  which  corre- 


68  OBSTETRICAL  NURSING 

sponds  to  the  first  six  weeks  of  pregnancy,  and  the  fetus  from 
then  until  the  time  of  delivery.  By  others  it  is  designated  the 
ovum  during  the  first  two  weeks  of  pregnancy,  the  embryo  from 
the  third  to  the  fifth  week,  after  which  it  is  known  as  the  fetus. 

From  the  nurse's  standpoint  these  distinctions  are  of  no 
consequence,  for  the  mass  may  safely  be  called  a  fetus  from 
the  time  that  the  expectant  mother  looks  to  the  nurse  for  guid- 
ance and  care. 

It  is  scarcely  warrantable  to  take  the  time  and  space  which 
would  be  necessary  to  trace  in  detail  through  its  various  stages 
the  intricate  development  of  the  human  body^  with  its  attached 
membranes.  But  the  whole  question  is  so  important  and  so 
interesting  that  we  shall  at  least  have  a  word  of  description  as 
to  its  size  and  characteristics  at  successive  periods. 

Although  the  exact  length  of  time  required  for  the  matura- 
tion of  the  fetus  is  not  known,  it  is  estimated  that  two  hundred 
and  eighty  days,  or  ten  lunar  months,  elapse  between  the  be- 
ginning of  the  last  menstrual  period  and  the  beginning  of  labor. 
And  in  spite  of  the  difference  in  size  among  the  mothers,  it  is 
found  that  the  products  of  conception  develop  and  grow  at  a 
fairly  uniform  rate  of  speed. 

A  new  human  being  is  the  ultimate  result  of  conception,  but 
the  chorion,  amnion,  placenta  and  umbilical  cord  must  also  be 
created  to  serve  as  aids  in  building  and  protecting  the  developing 
child  during  its  uterine  life.  The  part  played  by  these  accessory 
structures  is  so  vital,  in  spite  of  being  temporary,  that  it  will 
be  well  for  us  to  look  into  their  origin  and  functions  before  con- 
sidering the  fetus  itself  which  they  serve. 

The  Chorion  and  Placenta.  Very  early  in  pregnancy,  prob- 
ably while  the  fertilized  ovum  is  journeying  down  the  tube,  tiny, 
thread-like  projections,  called  villi,  appear  over  the  surface  of 
the  primitive  chorion,  giving  it  the  shaggy  appearance  of  a  chest- 
nut burr.  Shortly  after  this  shaggy  ovum  reaches  the  uterus 
and  is  embedded  in  the  lining,  the  chorion,  or  the  outer  fetal 
membrane,  is  formed,  being  partly  derived  from  the  ectodermal 
layer  of  cells  growing  within  the  blastodermal  vesicle.  The 
chorion  grows  rapidly  in  size  and  thickness,  and  the  villi  upon 
its  surface  increase  in  size,  number  and  complexity  by  frequent 


DEVELOPMENT  OF  THE  OVUM  AND  EMBRYO   69 


branching.  In  so  doing  the  villi  pusii  their  way  into  the  ma- 
ternal tissues  surrounding  them,  and  destroy  the  capillary  walls 
with  which  they  come  in  contact.  Maternal  blood  escapes  through 
the  destroyed  walls,  forming  tiny  hemorrhagic  areas,  or  "lakes 
of  blood."  The  chorionic  villi  float  freely  in  these  pools  of 
maternal  blood,  which  is  constantly  being  refreshed  by  an  in- 
flow of  arterial  and  an  outflow  of  venous  blood  through  the 
mother's  vessels. 

Blood  vessels  soon  appear  in  these  chorionic  villi,  and  fetal 


DlcLduQ  basalts 

(Plocenta) 


_,Chorlon    jrondosurn 


//M(__AbdoiTional  pedicle 
^Amnion 

Chorion    loeve 


-DlclduQ  CQpularLsj 
^J^-UterLne  cavLty 

~ -Uterine   ujoll 


Fig.  20. — Diagram  of  fetus,  cord,  membranes  and  placenta  in  utero  at  au 
early  stage  of  their  development. 

blood  then  circulates  through  them.  It  becomes  apparent,  there- 
fore, that  the  maternal  and  fetal  blood  streams  are  in  such  close 
relation  that  they  are  separated  by  only  the  thin  membrane  which 
forms  the  walls  of  the  vessels  in  the  villi.     (Fig.  20.) 

This  arrangement  makes  it  possible  for  the  steadily  proliferat- 
ing villi  to  discharge  one  of  their  functions,  which  is  to  receive 
from  the  maternal  blood  nourishment  for  the  embryo,  and  give 
up  to  the  parent  waste  products  from  the  growing  body.  This 
exchange  of  nourishment  and  waste  matter  takes  place  by  means 


70  OBSTETRICAL  NURSING 

of  osmosis.  But  freely  as  the  exchange  of  materials  occurs,  there 
is  never  any  contact,  or  mixing  of  maternal  and  fetal  blood,  nor 
does  maternal  blood  at  any  time  flow  through  fetal  vessels.  It 
was  believed  at  one  time  that  the  fetus  was  nourished  by  milk 
which  was  in  some  way  secreted  by  the  gravid  uterus,  but  this 
is  disproved  by  present  knowledge  of  the  placental  function. 

The  second  function  of  the  villi,  particularly  after  they  have 
developed  to  the  placental  stage,  is  to  assist  in  securely  attach- 
ing the  embryo  to  the  uterine  wall. 

The  villi  are  equally  distributed  over  the  surface  of  the  cho- 
rion at  first,  but  as  the  sac  increases  in  size  and  pushes  out  into 
the  uterine  cavity,  they  gradually  atrophy  and  disappear,  ex- 
cepting over  the  small  area  beneath  the  vesicle  where  the  chorion 
is  in  contact  with  the  decidua  basalis.  At  this  site  the  villi  be- 
come much  more  abundant,  and  it  is  here  that  the  placenta  even- 
tually develops.  This  part  of  the  chorion  is  termed  the  chorion 
frondosum,  while  the  remainder,  which  is  in  contact  with  the 
decidua  capsularis,  is  the  chorion  Ifrve. 

As  pregnancy  advances  and  the  fetal  sac  enlarges,  the 
chorion  laeve  covered  by  the  decidua  capsularis,  or  reflexa,  is 
pushed  farther  out  into  the  uterine  cavity,  until  finally  it  quite 
reaches  the  opposite  wall,  meets  the  decidua  vera  and  obliterates 
the  entire  space  which  had  existed  between  the  two  membranes. 
This  means  that  instead  of  a  uterine  cavity  lined  with  decidua, 
and  a  tiny  capsule  somewhere  off  to  the  side  lined  with  chorion, 
the  latter  has  distended  until  it  completely  fills  and  really  be- 
comes the  cavity  within  the  uterine  walls,  thus  lining  the  uterus 
with  chorion  and  crowding  the  original  lining  out  of  existence. 
The  decidudae  capsularis  and  vera  fuse  in  time  and  finally  the 
capsularis  degenerates  and  disappears. 

The  Amnion.  Returning  for  a  moment  to  the  blastodermal 
stage  of  the  ovum,  we  find  that  the  amnion,  or  inner  membrane, 
first  appears  as  a  tiny  vesicle  over  the  dorsal  surface  of  the  em- 
bryo. Very  soon,  however,  it  invests  the  embryo  completely,  and 
the  membranous  sac  is  intact,  excepting  where  it  is  pierced  by 
the  umbilical  cord.  The  amnion,  too,  is  derived  in  part  from 
the  ectoderm,  but  is  a  stronger,  denser  membrane  than  the  cho- 
rion.   At  first  there  is  an  appreciable  space,  and  some  fluid,  be- 


DEVELOPMENT  OF  THE  OVUJVI  AND  EMBllVO       71 

tween  the  two  membranes,  but  as  the  amnion  increases  in  size 
with  the  advance  of  pregnancy,  it  comes  in  contact  with  and  is 
loosely  adherent  to  the  chorion. 

Very  early  in  its  development  the  amniotic  sac  contains  a 
pale  yellow  fluid  known  as  the  amniotic  fluid,  or  liquor  amnii, 
in  which  the  fetus  floats.  This  fluid  increases  in  amount  until 
the  end  of  pregnancy  and  though  the  quantity  is  variable,  it 
usually  amounts  to  about  a  quart. 

The  source  of  the  liquor  amnii  is  not  definitely  known,  but 
it  is  generally  believed  to  be  of  maternal  origin,  secreted  from 
the  amniotic  membrane,  though  the  possibility  of  its  consisting 
partly  of  fetal  urine  cannot  be  overlooked.     It  is  about  99% 


Plcicenlo 


FiQ.  21. — Diagram  showing  general  structure  and  relation  of  membranes, 
placenta  and  cord. 


water,  containing  particles  of  dead  skin  and  lanugo,  a  soft  downy 
hair  cast  off  from  the  body  of  the  fetus,  traces  of  albumen  and 
both  organic  and  inorganic  salts. 

The  amniotic  fluid  serves  a  variety  of  purposes.  Since  the 
intestines  of  the  fetus  contain  lanugo  and  particles  of  dead 
skin,  it  is  evident  that  the  child  swallows  some  of  this  fluid  during 
its  uterine  life,  and  possibly  obtains  in  this  way  much  of  the 
fluid  necessary  for  its  development. 

The  increasing  bulk  of  the  fluid  serves  to  distend  the  fetal 
sac  and  surrounding  uterus,  and  thus  provides  the  fetus  with 
room  for  growth  and  movement.  It  also  prevents  adhesions  be- 
tween the  child's  skin  and  the  amnion,  which  are  a  factor,  when 
by  mischance  they  do  occur,  in  causing  monstrosities  and  intra- 
uterine amputations.     The  fluid  with  which  it  is  surrounded 


72 


OBSTETRICAL  NURSING 


keeps  the  fetus  at  an  equable  temperature  in  spite  of  variations 
of  temperature  in  the  mother's  environment,  and  minimizes  the 
danger  of  injury  to  the  fragile  little  body,  from  pressure  or 
blows  on  the  mother's  abdomen.  And  by  acting  as  a  water  wedge, 
forced  down  by  uterine  contractions  at  the  time  of  labor,  it  di- 


:; 

1^ 

A                      1 

i 

Pic 

1 

•.^"« 

'^ilg^UHIi 

^"^•^1 

1  ■     •  /    ' 

\        ^ 

:.   ..-H 

mr    >-  ■ 

r  -v 

1          , 

■  '             la-                              1 

'  '1 

4 

1' 

^^ 

mk 

'           -^                         ! 

t 

1 

k^ , 

^^ 

"^y^ 

,^0^ 

Fig.  22. — Placental  blood  vessels.  Note  their  branching,  tree-like 
arrangement.  (Photographed  from  an  injected  specimen  in  the  Obstetrical 
Laboratory,  Johns  Hopkins  Hospital.) 


lates  the  cervix  sufficiently  to  permit  the  expulsion  of  the  full 
term  child. 

The  placenta.  The  placenta,  in  lay  parlance  the  after-birth, 
is  really  a  thickened,  amplified  portion  of  the  fetal  sac,  which 
has  developed  at  the  site  of  the  implantation  of  the  ovum.  It  is 
partly  fetal  and  partly  maternal  in   origin,   being   developed 


DEVELOPMENT  OF  THE  OVUM  AND  EMBRYO   73 

jointly  from  the  chorion  fondosum  with  its  branching  villi,  and 
the  underlying  decidua  basalis. 

The  chorionic  villi  already  referred  to  grow  and  branch  in  a 
tree-like  fashion  (Fig.  22),  and  push  their  way  farther  and 
farther  into  the  uterine  tissues  creating  the  intervillous  spaces 
which  fill  with  maternal  blood.  From  the  time  that  the  first  fetal 
blood  vessels  appear  in  these  floating  villi,  until  the  child  is 
born,  there  is  a  constant  exchange  of  nutriment  and  waste  mat- 
ter between  the  maternal  and  fetal  blood ;  the  arterial  maternal 
blood  in  the  intervillous  spaces  giving  to  the  fetal  blood  in  the 
villi  the  oxygen  and  other  substances  necessary  to  nourish  and 
build  the  growing  young  body,  and  receiving  in  return  the 
broken-down  products  of  fetal  activity.  The  waste  is  carried 
by  the  maternal  blood  stream  to  the  mother 's  lungs,  kidneys  and 
skin,  by  which  it  is  excreted. 

This  exchange  of  substances  is  accomplished  by  osmosis  and 
also  by  selective  powers  of  the  cells  in  the  villi.  Thus  the  pla- 
centa virtually  serves  the  fetus  as  lungs,  stomach,  intestines  and 
kidneys  throughout  its  uterine  life. 

In  addition  to  the  nutritive  substances  in  the  mother's  blood, 
such  as  albumen,  iron  and  fat  which  are  so  altered  by  cell  action 
as  to  be  absorbable  through  the  villi,  certain  protective  sub- 
stances as  the  anti-toxines  of  diphtheria,  tetanus,  colon  and  ty- 
phoid bacilli  are  evidently  transmitted  from  the  maternal  to  the 
fetal  circulation.  It  is  claimed  by  some  authorities  that  patho- 
genic organisms,  for  example,  anthrax,  pneumonia  and  tubercle 
bacilli,  may  be  transmitted  from  mother  to  fetus,  but  the  re- 
ported cases  are  so  rare  that  the  accepted  belief  is  that  organisms 
are  seldom  transmitted,  if  the  placenta  is  healthy  and  intact. 
But,  according  to  Dr.  Williams,  the  transmission  of  typhoid 
occurs  frequently,  though  malarial  parasites  cannot  pass  through 
the  villous  membranes. 

Only  during  comparatively  recent  years  has  accurate  knowl- 
edge of  the  origin  and  function  of  the  placenta  been  available. 
Many  varied  and  interesting  beliefs  and  superstitions  gained 
currency  in  the  past,  but  all  of  them  were  erroneous. 

The  description  of  the  circulation  of  the  blood  by  William 
Harvey  in  1628  shed  considerable  light  upon  this  puzzling  ques- 


74 


OBSTETRICAL  NURSING 


tion  concerning  the  exchange  of  fuel  and  ash  between  the  parent 
and  fetal  bodies.    But  a  mistaken  belief  that  the  maternal  blood 


Fig.  23. — Maternal  surface  of  the  placenta,  surrounded  by  the  membranes 
and  cord.     (Prom  a  photograph  taken  at  Johns  Hopkins  Hospital.) 

actually  entered  and  jflowed  through  the  fetal  vessels  resulted 
from  his  valuable  discovery. 

When  we  examine  this  interesting  structure,  the  placenta, 


DEVELOPMENT  OF  THE  OVUM  AND  EMBRYO   75 

after  it  is  cast  off,  we  find  it  to  be  a  flattened,  fairly  round, 
spongy  mass,  eight  or  nine  inches  in  diameter,  about  an  inch 
thick  where  the  cord  arises  and  thinning  out  toward  the  margin. 
Continued  from  the  margin  are  the  filmy  fetal  membranes, 
which  together  form  a  ruptured  sac.    The  rupture  in  these  mem- 


FiG.   24. — Fetal  surface  of  the  placenta   showing   origin   of   cord.      (From 
photograph    taken    at    Johns    Hopkins    Hospital.) 

branes  is  the  opening  through  which  the  amniotic  fluid  escapes, 
and  the  child  passes  during  birth. 

The  placenta  weighs  about  a  pound  and  a  quarter,  or  1/6  as 
much  as  the  child,  and  accordingly  varies  in  size  and  weight  with 
the  baby.  The  maternal  surface  (Fig.  23)  having  been  detached 
from  the  uterine  wall,  is  rough  and  bleeding  and  is  irregularly 
divided  into  lobes  while  the  inner,  or  fetal,  surface  is  smooth 


76  OBSTETRICAL  NURSING 

and  glistening  and  covered  with  the  amnion.  The  fetal  surface 
(Fig.  24)  is  traversed  by  a  number  of  large  blood-vessels  which 
converge  toward  the  point  of  insertion  of  the  umbilical  cord, 
from  the  vessels  of  which  they  really  arise.  These  vessels  branch 
and  divide  until  their  termination  in  the  innumerable  chorionic 
villi  floating  in  the  lakes  of  maternal  blood. 

The  Umbilical  Cord.  The  cord,  or  funis,  is  a  bluish  white 
cord  about  three-quarters  of  an  inch  in  diameter,  twisted  and 
tortuous  throughout  its  length  of  about  twenty  inches.  It  is  the 
one  actual  link  between  the  mother  and  her  unborn  child,  one 
end  being  attached  to  the  abdomen  of  the  fetus,  about  midway 
between  the  ensiform  and  the  pubis,  and  the  other  to  the  inner 
surface  of  the  placenta.  The  cord  is  derived  from  the  abdominal 
pedicle  and  is  merely  an  extension  of  the  caudal  or  tail  end  of 
the  embryo.  It  is  covered  with  a  layer  of  ectoderm  which  i&' 
continuous  with  the  ectodermal  covering  of  the  fetus. 

The  cord  consists  of  a  gelatinous  mass  known  as  Wharton's 
jelly,  in  the  centre  of  which  are  embedded  three  blood  vessels; 
two  arteries  through  which  the  vitiated  blood  flows  to  the  pla- 
centa, whero  it  gives  up  its  ash;  and  one  vein  which  carries 
oxygenated,  nourishment-bearing  blood  back  to  the  fetus.  The 
life  of  the  fetus,  therefore,  is  absolutely  contingent  upon  an 
uninterrupted,  two-way  flow  of  blood  through  the  cord. 

Tha  Fetus.  In  tracing  the  development  of  the  ovum  after 
its  implantation  in  the  uterine  lining,  we  begin,  as  previously 
stated,  with  a  shaggy-looking  vesicle,  containing  fluid,  with  a 
clump  of  cells  hanging  toward  the  centre  from  their  point  of 
attachment  on  the  inner  surface  of  the  sac.  This  clump  devel- 
ops into  the  embryo. 

During  the  first  month  the  mass  increases  in  size,  becomes 
somewhat  elongated  and  curved  upon  itself  with  the  two  ex- 
tremities almost  in  contact.  The  abdominal  pedicle,  which  later 
becomes  the  umbilical  cord,  appears ;  the  alimentary  canal  exists 
as  a  straight  tube  and  the  thymus,  thyroid,  lungs  and  liver  are 
recognizable.  The  heart,  eyes,  nose,  ears,  and  brain  appear  in 
rudimentary  form  and  the  extremities  begin  to  be  evident  as 
tiny,  bud-like  projections  on  the  surface  of  the  embryo. 

By  the  end  of  the  fourth  W3ek  the  sac  is  about  the  size  of 


DEVELOPMENT  OF  THE  OVUM  AND  EMBRYO   77 

a  pigeon's  egg  and  has  two  walls.  The  outer  wall,  or  chorion, 
as  we  have  already  seen,  is  covered  with  villi,  and  the  amnion, 
or  inner  wall,  is  smooth ;  the  contained  embryo  is  surrounded  by 
amniotic  fluid  and  measures  about  10  millimetres  or  .4  inch  in 
length. 

By  the  end  of  the  second  month,  or  eighth  week,  the  head 
end  of  the  embryo  has  greatly  increased  in  size  and  is  about  as 


Fig.  25. — Embryo,  about  5.5  centimetres  long  in  amniotic  sac;  uterine 
wall  incised,  chorion  split  and  turned  back.  Drawn  by  Max  BrodeL 
(From  The  Umbilicus  and  Its  Diseases,  by  Thomas  R.  Cullen,  M.D.) 


large  as  the  rest  of  the  body.  Bone  centres  appear  in  the  rudi- 
mentary clavicles;  the  kidneys  and  supra-renal  bodies  are 
formed;  the  limbs  are  more  developed,  webbed  hands  and  feet 
are  formed,  the  external  genitalia  are  apparent  but  the  sex  is  not 
distinguishable.     The  amnion  is  distended  with  fluid,  but  it  is 


78 


OBSTETRICAL  NURSING 


not  yet  in  contact  with  the  chorion ;  the  chorionic  villi  have  be- 
come more  luxuriant  on  that  part  of  the  chorion  resting  on  the 
decidua  basalis,  the  future  site  of  the  placenta.  The  approximate 
weight  of  the  embryo  is  4  grams  and  its  length  25  millimetres 
or  an  inch. 

By  the  end  of  the  third  month,  or  twelfth  week,  centres  of 
ossification  have  appeared  in  most  of  the  bones,  the  fingers  and 


€Days.     21  Days.  30Doys,  aADoijs.     e^Ulceks 


tn*  of    e  md  End  of    3 mo.  End    of     4  TTIa 

Fig.  26. — Diagram  showing  appearance  of  fetus  at  different  stages  in  its 

development. 


toes  are  separated  and  bear  nails  in  the  form  of  fine  membranes ; 
the  umbilical  cord  has  definite  form,  has  increased  in  length  and 
begun  to  twist.  The  neck  is  longer,  teeth  are  forming  and  the 
eyes  have  lids.  The  amnion  and  chorion  are  now  in  contact,  and 
the  villi  have  disappeared  excepting  at  one  point  where  a  small, 
but  complete  placenta  has  developed.  The  embryo  is  about  9 
centimetres  long  and  weighs  about  30  grams. 

By  the  end  of  the  fourth  month,  or  sixteenth  week,  all  parts 
show  growth  and  development;  lanugo  appears  over  the  body; 


DEVELOPMENT  OF  THE  OVUM  AND  EMBRYO   79 

the  sex  organs  are  clearly  distinguishable  and  there  is  tarry  fse- 
cal  matter,  called  meconium,  in  the  intestines.  The  placenta  is 
larger,  the  cord  longer,  more  spiral  and  also  thicker  because  of 
the  Whartonian  jelly  which  is  beginning  to  form.  The  fetus  is 
about  15  centimetres  long  and  weighs  about  120  grams. 

By  the  end  of  the  fifth  month,  or  twentieth  week,  the  fetus 
has  both  grown  and  developed  markedly.  It  is  now  covered  with 
skin  on  which  are  occasional  patches  of  vernix  caseosa,  a  greasy, 
cheesy  substance  consisting  largely  of  a  secretion  of  the  seba- 
ceous glands.  There  is  some  fat  beneath  the  skin  but  tlie  face 
looks  old  and  wrinkled.  Hair  has  appeared  upon  the  head  and 
the  eyelids  are  opening.  It  is  usually  during  the  fifth  month 
that  the  expectant  mother  first  feels  the  fetal  movements  which 
are  commonly  referred  to  as  "quickening."  The  body  is  about 
25  centimetres  long  and  weighs  about  280  grams. 

By  the  end  of  the  seventh  month,  or  twenty-eighth  week,  the 
fetus  still  looks  thin  and  scraA\aiy,  the  skin  is  reddish  and  is 
well  covered  with  vernix  caseosa  and  the  intestines  contain  an 
increased  amount  of  meconium.  If  born  at  this  time  the  child 
will  move  quite  vigorously  and  cry  feebly.  Although  it  is  not 
likely  to  live  for  any  length  of  time,  every  effort  should  be  made 
to  save  its  life,  for  it  may  be  that  the  high  rate  of  mortality  at 
this  age  is  due  to  the  inadequacy  of  the  attempts  which  are  usu- 
ally made  to  save  the  child  rather  than  to  the  frailty  of  the  child 
itself.  It  is  about  35  centimetres  long  and  weighs  about  1200 
grams. 

By  the  end  of  the  eighth  month,  or  thirty-second  week,  the 
child  has  grown  to  about  42  centimetres  in  length  and  1900  grams 
in  weight,  but  continues  to  look  thin  and  old  and  wrinkled.  Tlie 
nails  do  not  extend  beyond  the  ends  of  the  fingers  but  are  firmer 
in  texture;  the  lanugo  begins  to  disappear  from  the  face  but 
the  hair  on  the  head  is  more  abundant.  If  born  at  this  stage,  the 
baby  will  have  a  fair  chance  to  live,  if  given  painstaking  care. 
This  is  true  in  spite  of  the  ancient  superstition,  still  widely  cur- 
rent, that  a  seven  months'  baby  is  more  viable  than  one  boni  at 
eight  months  (meaning  calendar  months).  The  fact  is  that  after 
the  eighth  lunar  month,  a  little  more  than  seven  calendar  months, 


80  OBSTETRICAL  NURSING 

the  probability  of  the  child's  living  increases  rapidly  with  the 
length  of  its  intra-uterine  life. 

By  the  end  of  the  ninth  month,  or  thirty-sixth  week,  the  in- 
creased deposit  of  fat  under  the  skin  has  given  a  plumper, 
rounder  contour  to  the  entire  body;  the  aged  look  has  passed 
and  the  chances  for  life  have  greatly  increased.  The  baby  now 
weighs  about  2500  grams  and  is  about  46  centimetres  long. 

The  end  of  the  tenth  month,  or  fortieth  week,  usually  marks 
the  end  of  pregnancy.  (Fig.  27.)  The  average,  normally  de- 
veloped baby  has  attained  a  length  of  50  centimetres  (20  inches), 
and  a  weight  of  3250  grams,  or  about  714  pounds,  boys  usually 
being  about  three  ounces  heavier  than  girls. 

It  must  be  remembered,  however,  that  these  figures  merely 
represent  the  average  drawn  from  a  large  number  of  cases,  for 
there  may  be  a  variation  in  weight  among  entirely  normal 
healthy  babies  from  a  minimum  of  2300  grams  (5  pounds)  to  as 
high  as  5000  grams  (11  pounds),  or  more.  Babies  actually 
weighing  more  than  12  pounds  are  seldom  born,  in  spite  of 
legends  and  rumors  to  the  contrary. 

The  length  of  a  normal  baby  is  less  variable  than  the  weight. 
In  fact,  it  is  so  nearly  constant  in  its  increase  during  the  suc- 
cessive months  of  pregnancy,  that  the  age  of  a  prematurely  born 
fetus  may  be  fairly  accurately  estimated  from  its  length.  This 
fact  is  of  no  little  practical  importance,  since  it  aids  the  obstetri- 
cian in  making  a  prognosis  as  to  the  child's  prospect  of  living, 
for  he  can  estimate  its  intra-uterine  age  from  its  body  length. 

The  size  of  the  baby  is  affected  by  race,  colored  babies,  for 
example,  averaging  a  smaller  weight  than  white  babies.  And, 
a;s  might  be  expected,  the  size  of  the  parents  is  likely  to  be  re- 
flected in  the  size  of  their  infants,  large  parents  tending  to  have 
large  children  and  vice  versa. 

The  number  of  children  which  the  mother  has  previously 
borne  is  also  a  factor,  since  the  first  child  is  usually  the  smallest, 
the  size  of  those  following  showing  an  increase  with  the  mother's 
age  up  to  her  twenty-eighth  or  thirtieth  year,  provided  the  suc- 
cessive pregnancies  do  not  occur  at  too  frequent  intervals. 

The  expectant  mother's  general  state  of  health,  her  state  of 
nutrition,  the  character  of  her  surroundings  and  her  mode  of 


DEVELOPMENT  OP  THE  OVUM  AND  EMBRYO   81 

living  may  be  expected  to  influence  her  baby's  welfare.  Hence, 
women  who  live  in  comfortable,  or  luxurious  circumstances  usu- 
allj'  have  more  robust  babies  than  those  who  are  run  down,  poorly 


FlO.  27. — Full  term   fetus   in   utero.     Drawn   by   Max   Brodel.      (Used   by 
permission  of  A.  J.  Nystrom  &Co.,  Chicago.) 

nourished  or  overworked.  All  of  which  hints  at  the  great  value 
of  prenatal  care  which  will  be  taken  up  in  detail  in  a  later 
chapter. 


82  OBSTETRICAL  NURSING 

A  multiple  pregnancy  is  one  in  which  the  pregnant  uterus 
contains  two  or  more  embryos,  these  being  termed  twins  when 
there  are  two  and  triplets  when  there  are  three;  quadruplets, 
quintuplets  and  sextuplets  when  there  are  four,  five  and  six  em- 
bryos, respectively,  six  being  the  largest  accredited  number  on 
record. 

The  tendency  to  multiple  i^regnancies  is  apparently  inherited, 
and  it  sometimes  happens  that  several  members  of  the  same 
family  connection  have  this  predisposition,  as  evidenced  by  the 
number  of  twins  and  triplets  to  be  found  among  relatives.  It  is 
estimated  that  twins  occur  once  in  90  pregnancies  and  triplets 
once  in  about  7000  cases. 

Twin  pregnancies  may  result  from  the  fertilization  of  one 
or  of  two  ova,  and  are  designated  as  single  ovum  or  double  ovum 
twins  respectively.  In  single  ovum  twins  the  egg  becomes  di- 
vided early  in  its  development  and  two  embryos  are  formed.  In 
such  a  case  there  is  one  placenta,  one  chorion  and  two  amnions 
and  the  babies  are  of  the  same  sex. 

In  double  ovum  twins  two  ova  are  fertilized ;  both  may  come 
from  the  same  ovary  or  there  may  be  one  from  each  side.  When 
double  ovum  twins  occur,  there  are  two  placentae,  as  a  rule, 
though  they  may  be  somewhat  fused ;  two  amnions  and  two  cho- 
rions and  the  babies  may  be  of  the  same  sex  or  each  of  a  different 
sex. 

Twins  are  often  prematurely  born  and  each  one  is  likely  to 
be  smaller  than  a  baby  resulting  from  a  single  pregnancy,  but 
their  combined  weight  is  greater  than  that  of  one  normal  baby. 

An  extra-uterine  pregnancy  may  be  defined  as  a  pregnancy 
which  develops  outside  of  the  uterus,  usually  in  a  tube  or  ovary. 
Although  in  the  normal  course  of  events  the  fertilized  ovum 
travels  down  the  tube  and  becomes  attached  to  the  uterine  lining, 
it  is  possible  for  it  to  stop,  and  more  or  less  completely  develop 
at  any  point  along  the  way  between  the  Graafian  follicle,  from 
which  it  has  been  projected,  and  the  uterus  toward  which  it  is 
traveling.  If  the  fetus  develops  in  the  ovary,  it  is  termed  an 
ovarian  pregnancy,  and  a  tubal  pregnancy  if  it  occurs  in  the 
tube,  the  latter  being  the  most  frequent  variety  of  extra-uterine 
pregnancy. 


DEVELOPMENT  OF  THE  OVUM  AND  EMBRYO   83 

In  the  opinion  of  Dr.  Mall,  only  about  1  per  cent  of  all  extra- 
uterine pregnancies  are  capable  of  going  to  term.  There  may  be 
an  abortion,  when  the  fetus  and  membranes  are  partly  or  com- 
pletely extruded  from  the  fimbriated  end  of  the  tube  into  the 
peritoneal  cavity;  or  a  rupture  of  the  tube,  when  the  fetus, 
with  or  without  the  membranes,  may  be  expelled  into  the  peri- 
toneal cavity,  or  between  the  folds  of  the.  broad  ligament.  If 
the  greater  part  of  the  placenta  remains  attached  to  the  site  of 
its  development,  in  the  case  of  a  ruptured  tube,  it  is  possible  for 
the  fetus  to  live  and  grow  and  even  go  to  term.  But  if  the 
placenta  is  nearly,  or  completely  separated,  the  fetus  perishes 
and  may  be  largely  absorbed  by  the  maternal  organism,  or 
mummified,  or  putrefactive  changes  may  take  place.  It  is  usu- 
ally customary  to  terminate  an  extra-uterine  pregnancy  as  soon 
as  it  is  diagnosed,  for  only  a  very  small  number  can  be  expected 
to  go  to  term,  the  majority  aborting,  or  rupturing  the  tube,  with 
serious  hemorrhage  from  the  mother  as  a  frequent  result. 

To  sum  up  the  normal  pregnancy,  we  find  that  in  the  course 
of  ten  lunar  months,  following  the  fertilization  of  an  ovum,  the 
uterus  grows  from  a  small,  flattened,  pelvic  organ,  three  inches 
in  length,  to  a  large,  globular,  muscular  sac,  constituting  an 
abdominal  tumor  about  fifteen  inches  long ;  it  increases  its  weight 
sixteen  times,  that  is  from  two  ounces  to  two  pounds,  while 
the  capacity  of  the  uterine  cavity  is  multiplied  five  hundred 
times.  Within  the  cavity  is  a  child  weighing  about  seven  and  a 
quarter  pounds,  surrounded  by  a  quart  or  so  of  amniotic  fluid. 
This  fluid  is  contained  in  the  sac  composed  of  the  fetal  mem- 
branes, the  amnion  and  chorion,  which  are  excessively  developed 
at  one  point  into  the  placenta.  The  placenta,  in  turn,  is  at- 
tached to  the  child  by  means  of  the  umbilical  cord.  The  total 
weight  of  the  uterus  and  its  contents  at  term  is  usually  about 
fifteen  pounds. 

Quite  as  mj^sterious  and  inexplicable  as  the  development  of 
these  complex  structures  from  one  tiny  cell  is  the  fact  that  when 
the  new  human  being  is  ready  to  begin  life  as  a  separate  entity, 
further  changes  occur  within  the  mother's  body  which  produce 
uterine  contractions  of  such  a  character  as  to  entirely  empty  tlie 
uterus  of  its  contents. 


CHAPTER  IV 
GROWTH   AND   PHYSIOLOGY    OF    THE    FETUS 

Although  the  fetus  at  term  is  in  many  respects  simply  a 
diminutive,  immature  man,  or  woman,  its  anatomy  and  physiol- 
ogy present  certain  characteristics  which  have  adapted  it  to  a 
protected  existence  in  a  sac  of  fluid.  Some  of  the  fetal  struc- 
tures and  functions  become  increasingly  active  after  birth,  while 
others  subside  and  disappear. 

We  have  seen  that  after  the  first  month  of  pregnancy  the 
placenta  serves  the  fetus  as  a  combined  respiratory  and  diges- 
tive apparatus,  not  alone  in  supplying  the  oxygen  and  nourish- 
ment requisite  for  life  and  growth,  but  also  in  excreting  the 
broken-down  products  of  fetal  life.  It  apparently  acts  some- 
what as  a  liver,  too,  in  performing  something  akin  to  a  glyco- 
genic function. 

Obviously,  then,  the  fetus  must  possess  a  circulatory  mech- 
anism which  is  peculiar  to  itself  alone,  and  not  found  in  the  in- 
dependently existing  human  body,  in  which  the  lungs  and  ali- 
mentary tract  are  functioning  as  intended.  This  mechanism  is 
provided  by  means  of  certain  structures  which  exist  in  the  fetal 
circulatory  system  and  which  automatically  disappear  shortly 
after  birth.  The  nurse  must  be  aware  of  these  anatomical 
changes  that  take  place,  in  addition  to  growth,  if  she  is  to  have 
an  intelligent  grasp  of  her  tiny  patient's  possible  needs. 

The  structures  which  change  or  disappear  after  birth  are  the 
foramen  ovale,  a  direct  opening  between  the  right  and  left  auri- 
cles, and  four  blood  vessels:  the  ductus  arteriosus,  ductus  venosus 
and  the  two  hypogastric  arteries.  An  understanding  of  the  func- 
tions of  these  vessels  involves  an  understanding  of  the  course 
followed  by  the  fetal  blood  currents,  as  indicated  in  Fig.  28, 
page  85. 

We  see  that  there  are  three  vessels  within  the  umbilical  cord : 
the  umbilical  vein  and  two  arteries.    In  spite  of  its  name,  the  vein 

84 


GROWTH  AND  PHYSIOLOGY  OF  THE  FETUS   85 

conveys  arterial  blood  from  the  placenta  to  the  fetus.  After 
piercing  the  baby's  abdominal  wall,  it  divides  into  two  vessels; 
the  larger  one,  called  the  ductus  venosus,  empties  into  the  in- 
ferior or  ascending  vena  cava,  while  the  smaller  branch  joins  the 


Fig.  28. — Diagram  showing  course  of  fetal  circulation  through  hypo- 
gastric arteries,  ductus  venosus,  ductus  arteriosis  and  the  foramen  ovale. 
(From  The  American  Text  Book  on  Obstetrics.) 


portal  vein,  which  enters  the  liver.  The  relatively  large  amount 
of  arterial  blood  sent  directly  to  the  liver  may  in  part  account 
for  the  large  size  of  this  organ  in  the  fetus.  Upon  its  emergence 
from  the  liver,  this  blood  stream  flow's  into  the  inferior  vena  cava 


8G  OBSTETRICAL  NURSING 

The  ascending  vena  cava,  then,  pours  into  the  right  auricle  a 
mixture  of  arterial  blood,  which  has  come  directly  from  the  pla- 
centa, and  venous  blood  returned  from  the  liver,  intestines  and 
lower  extremities.  There  is  a  difference  of  opinion  concerning 
the  course  of  the  blood  stream  after  reaching  the  right  auricle. 
The  general  teaching,  however,  is  that  the  eustachian  valve, 
guarding  the  foramen  ovale,  deflects  the  current  through  this 
opening  from  the  right  into  the  left  auricle.  It  then  pours  into 
the  left  ventricle,  is  pumped  into  the  arch  of  the  aorta,  from 
which  most  of  the  blood  is  sent  to  the  head  and  upper  extremities, 
though  a  small  part  carries  nourishment  to  other  parts  of  the 
body. 

The  descending,  or  superior^  vena  cava,  carrying  blood  re- 
turning from  the  head  and  arms  also  empties  into  the  right  au- 
ricle ;  this  stream  presumably  crosses  the  stream  which  is  directed 
toward  the  foramen  ovale,  flows  into  the  right  ventricle  by  which 
it  is  pumped  into  the  pulmonary  artery.  The  circulation  of 
blood  through  the  lungs,  however,  is  for  their  own  nourishment, 
and  not  for  aeration  as  with  the  adult.  For  this  reason  most  of 
the  contents  of  the  fetal  pulmonary  artery  empties  into  the 
aorta  through  the  ductus  arteriosus,  one  of  the  temporary  fetal 
structures  already  referred  to.  From  the  aorta  the  stream  is 
directed  in  part  to  the  lower  extremities  and  the  pelvic  and  ab- 
dominal viscera,  but  most  of  it  flows  into  the  hypogastric  ar- 
teries. These  are  also  temporary  arteries.  They  lead  to  the 
umbilical  cord  and,  as  the  umbilical  arteries,  carry  the  venous  or 
vitiated  blood  through  the  cord  to  the  placenta  where  it  is  oxy- 
genated, freed  of  its  waste  in  the  chorionic  villi  and  returned  to 
the  fetus  through  the  umbilical  vein. 

As  soon  as  the  child  is  born  and  it  is  obliged  to  obtain  its 
oxygen  from  the  surrounding  air,  its  pulmonary  circulation  of 
necessity  becomes  immediately  more  important  and  is  greatly 
increased  in  volume.  In  fact,  the  entire  fetal  circulation  is 
readjusted  to  meet  the  needs  of  the  new  and  independent  func- 
tions which  the  little  body  now  assumes.  The  temporary  struc- 
tures are  obliterated,  since  they  are  no  longer  needed,  and  the 
lungs  and  intestines  become  more  active  in  compensation. 

As  the  ductus  venosus  and  hypogastric  arteries  terminate  in 


GROWTH  AND  PHYSIOLOGY  OF  THE  FETUS   87 

blind  ends  and  become  useless  as  soon  as  the  umbilical  cord  is 
cut,  they  soon  begin  to  atrophy  and  are  obliterated  within  a  few 
days  after  birth.  This  means  tliat  less  blood  is  poured  into  the 
right  auricle,  which  naturally  results  in  relatively  less  tension  in 


Fig.  29. — Diagram  showing  circulation  of  the  blood  after  birth,  with 
hypogastric  arteries,  ductus  venosus,  ductus  arteriosis  and  foramen  ovale 
in  process  of  obliteration  and  pulmonary  circulation  greatly  increased. 
(From  The  American  Textbook  on  Obstetrics.) 

the  right  heart  and  an  increased  pressure  in  the  left,  which  tends 
to  close  the  foramen  ovale.  The  foramen  ovale  does  not  entirely 
disappear  at  once,  however,  but  closes  gradually,  sometimes  re- 
maining open  for  months.  Occasionally  it  remains  open  per- 
manentl3%  and  though  some  people  have  gone  through  life  com- 


88  OBSTETRICAL  NURSING 

fortably  with  a  patent  foramen  ovale,  its  ultimate  failure  to  close 
usually  results  in  serious  circulatory  trouble.  This  is  also  true 
of  the  ductus  arteriosus,  which  sometimes,  but  not  often,  fails  to 
close. 

The  rule  is  that  as  the  lungs  expand  and  an  increased  amount 
of  blood  is  carried  to  them  for  aeration,  the  ductus  arteriosus  de- 
flects a  steadily  diminishing  stream  from  the  right  ventricle  to 
the  arch  of  the  aorta.  Thus  it  gradually  ceases  functioning  in 
most  cases  and  disappears  in  the  course  of  a  few  weeks.  The 
abandoned  vessels  may  degenerate  and  disappear  in  time  or 
they  may  persist  in  the  form  of  small  fibrous  cords.     (Fig.  29.) 

Although  the  circulatory  system  shows  the  most  elaborate  ad- 
justments to  the  protection  afforded  by  intra-uterine  life,  there 
are  also  other  adaptations  made  by  the  fetal  organism. 

The  baby  acquires  about  90  per  cent  of  its  weight  during  the 
latter  half  of  pregnancy,  as  well  as  a  steadily  increasing  propor- 
tion of  solids  and  a  decrease  of  fluids  in  its  tissues,  for  in  its  early 
days  the  embryo  consists  largely  of  water.  But  for  all  of  that,  its 
existence  and  growth  in  utero,  and  the  functioning  of  its  heat 
producing  centre  require  surprisingly  little  oxygen  and  nourish- 
ment. The  amniotic  fluid  keeps  the  fetus  at  an  equable  tem- 
perature, about  1°  above  that  of  the  mother,  and  as  space  within 
the  uterine  cavity  permits  of  only  limited  movement,  there  is 
very  little  combustion  for  the  liberation  of  heat  and  energy. 

The  kidneys  assume  functional  form  at  a  very  early  fetal 
age,  probably  about  the  seventh  week,  and  the  presence  of  albu- 
men and  urea  in  the  amniotic  fluid  suggest  that  small  amounts 
of  urine  may  be  voided,  particularly  during  the  latter  part  of 
pregnancy. 

The  bowels,  on  the  other  hand,  are  normally  inactive,  this  is 
spite  of  the  fact  that  the  baby  evidently  obtains  fluid,  and  pos- 
sibly some  nutriment  by  swallowing  amniotic  fluid.  But  a  dis- 
charge of  meconium  may  be  caused  by  pressure  on  the  cord  or 
by  any  condition  which  interferes  with  the  umbilical  circulation. 
For  this  reason,  meconium  stained  fluid  escaping  during  labor 
in  a  head  presentation  may  be  taken  as  an  evidence  of  imminent 
asphyxiation,  due  to  an  interruption  of  the  umbilical  circulation. 

The  head  is  the  most  important  part  of  the  fetus,  from  an 


GROWTH  AND  PHYSIOLOGY  OF  THE  FETUS      89 

obstetrical  standpoint,  since  the  process  of  labor  is  virtually  a 
series  of  adaptations  of  the  size,  shape  and  position  of  the  fetal 
skull  to  the  size  and  shape  of  the  maternal  pelvis.  And  since  the 
pelvis  is  rigid  and  inflexible  the  adjustment  must  all  be  made 
by  the  fetal  headj-  which  is  mouldable  because  of  being  incom- 
pletely ossified  at  birth.  If  the  head  passes  through  the  inlet 
safely,  the  rest  of  the  delivery  will  usually  be  accomplished  with 
comparative  safety.  But  a  marked  disproportion  between  the 
diameters  of  the  head  and  pelvis,  or  limited  mouldability  of  the 
head,  constitutes  a  serious  complication,  which  will  be  discussed 
later  in  connection  with  obstetrical  operations. 

A  baby's  head  is  larger,  in  proportion  to  its  body,  than  an 
adult's,  while  the  face  forms  a  relatively  smaller  part  of  the 
baby's  than  of  the  adult's  head.  The  major  portion  is  the  dome 
or  vault-like  structure  forming  the  top,  sides  and  back  of  the 
head,  which  in  turn  is  made  up  of  separate  and  as  yet  ununited 
bones.  They  are  the  two  frontal,  two  parietal,  two  temporal  and 
the  occipital  bone,  with  which  the  wings  of  the  sphenoid  bones, 
though  less  important,  may  be  included. 

These  bones  are  not  joined  in  the  fetal  skull,  but  are  sepa- 
rate structures,  with  soft,  membranous  spaces  between  their  mar- 
gins, called  sutures;  while  the  irregular  spaces  formed  by  the 
intersection  of  two  or  more  sutures  are  called  fontanelles,  pos- 
sibly so  called  by  the  early  observers  because  the  pulsation  of 
the  soft  tissues  beneath  these  spaces  suggests  the  spurting  of  a 
fountain. 

The  sutures  are  named  and  situated  as  follows:  The  frontal 
lies  between  the  two  frontal  bones;  the  sagittal  extends  antero- 
posteriorly  between  the  parietal  bones;  the  coronal  between  the 
frontal  bones  and  the  anterior  margins  of  the  parietal,  while  the 
lamhdoidal  suture  separates  the  posterior  margin  of  the  parietal 
from  the  upper  margin  of  the  occipital  bone.  There  are  also  the 
temporal  sutures  between  the  upper  margins  of  the  temporal 
bones  and  the  lower  margins  of  the  two  parietals,  but  they  are 
of  no  obstetrical  importance,  as  they  cannot  be  felt  on  vaginal 
examination.     (Fig.  30.) 

There  are  two  fontanelles  of  obstetrical  significance.  The 
greater,  or  anterior  fontanelle,  also  called  the  hragma  or  sinci- 


90 


OBSTETRICAL  NURSING 


put,  is  located  at  the  meeting  of  the  coronal,  sagittal  and  frontal 
sutures.  It  is  diamond  or  lozenge  shaped,  about  an  inch  in 
diameter  and  is  not  obliterated  during  labor. 

The  smaller  or  posterior  fontanelle  is  the  triangular  space  at 
the  inter-section  of  the  sagittal  and  lambdoidaj  sutures,  and  may 


Fig.    30. — Side   and   top  views   of   fetal   skull   giving    average   length   of 
important   diameters. 

be  obliterated  as  the  surrounding  bony  margins  approach  each 
other  during  labor. 

The  coronal,  frontal,  lambdoid  and  sagittal  sutures  and  the 
anterior  and  posterior  fontanelles  are  of  greatest  diagnostic  value 
as  they  can  be  felt  through  the  vagina  during  labor.    It  is  by 


GROWTH  AND  PHYSIOLOGY  OP  THE  FETUS   91 

recognizing  and  locating  these  sutures  and  fontanelles  at  this 
time  that  the  accoucheur  is  enabled  to  determine  the  exact  posi- 
tion and  presentation  of  the  fetus. 

The  fact  that  the  skull  is  made  up  of  separate  bones,  with 
soft  membranous  spaces  interposed  between  them,  permits  of  its 
being  compressed  or  moulded  to  a  considerable  extent  as  it  passes 
through  the  birth  canal.  ()pi)osing  margins  may  meet,  or  even 
overlap,  to  such  a  degree  that  the  diameter  of  tlie  head  will  be 
appreciably  diminished  and  permit  of  its  passage  through  a  rela- 
tively narrow  canal.  This  mouldability  varies  greatly,  however, 
and  the  difference  in  the  degree  of  compressibility  of  heads  of 
approximately  the  same  size  may  spell  the  difference  between  an 
easy  and  a  difficult,  or  even  an  impossible  labor. 

A  new-born  baby 's  head  may  be  so  distorted  and  elongated  by 
the  moulding  process  that  it  is  unsightly  and  gives  the  young 
mother  great  concern.  But  the  nurse  can  be  quite  confident  in 
her  assurances  that  the  little  head  will  assume  its  normal, 
rounded  outline  in  a  very  few  days. 

The  five  most  important  diameters  of  the  new-born  baby's 
head  are : 

1.  The  occipitot-frontal  (abbreviation,  O.F.),  measured  from  the 
root  of  the  nose  to  the  occipital  protuberance,  is  11.75  centimetres. 

2.  The  biparietal  (B.I.P.)  is  the  longest  transverse  diameter, 
being  the  distance  between  the  parietal  protuberances,  and  measures 
9.25  centimetres. 

3.  The  bi-temporal  (B.T.)  is  the  greatest  distance  between  the 
temporal  bones  and  measures  8  centimetres. 

4.  The  occipito-mental  (O.M.)  is  the  gi-eatest  distance  from  the 
lower  margin  of  the  chin  to  a  point  on  the  posterior  extremity  of  the 
sagittal  suture,  and  measures  13.5  centimetres. 

5.  The  sub-occipito  bregmatic  (S.O.B.)  is  measured  from  the 
under  surface  of  the  occiput,  where  it  joins  the  neck,  to  the  centre 
of  the  anterior  fontanelle,  a  distance  of  9.5  centimetres. 

The  greatest  circumference  of  the  fetal  head  is  at  the  plane 
of  the  occipito-mental  and  biparietal  diameters  and  measures 
38  centimetres.  The  smallest  circumference  is  at  the  plane  of 
the  sub-occipito-bregmatic  and  biparietal  diameters,  and  meas- 
ures 28  centimetres. 


92  OBSTETRICAL  NURSING 

These  figures,  however,  like  all  of  those  which  it  is  possible 
to  give,  simply  represent  averages  taken  from  a  large  number 
of  cases.  Individual  variations  will  be  found  among  normal 
babies,  for  boys'  heads,  for  example,  are  usually  larger  than  girls' 
while  the  head  of  the  first  child  is  likely  to  be  smaller  than  the 
heads  of  those  born  subsequently. 


CHAPTER  V 
SIGNS,  SYMPTOMS,  AND  PHYSIOLOGY  OF  PREGNANCY 

Signs  and  Symptoms  of  Pregnancy.  Unfortunately  for  all 
parties  concerned,  the  exact  duration  of  pregnancy  has  never 
been  ascertained,  since  there  is  no  way  of  knowing  wlien  the  ovum 
is  fertilised,  the  moment  which  marks  the  beginning  of  preg- 
nancy. 

It  is  obviously  impossible,  therefore,  to  foretell  exactly  the 
date  of  confinement.  But  labor  usually  begins  about  ten  lunar 
months,  forty  weeks  or  from  273  to  280  days  after  the  onset  of 
the  last  menstrual  period. 

Thus  the  approximate  date  of  confinement  may  be  estimated 
by  counting  forward  280  days  or  backward  85  days  from  the  first 
day  of  the  last  period.  Or  what  is  perhaps  simpler,  and  amounts 
to  the  same  thing,  one  may  add  seven  days  to  the  onset  of  the 
last  period  and  count  back  three  months.  For  example,  if  the 
last  period  began  on  June  third,  the  addition  of  seven  days  giyes 
June  tenth,  while  counting  back  three  months  indicates  March 
tenth  as  the  approximate  date  upon  which  the  confinement  may 
be  expected. 

This  is  probably  as  satisfactory  as  any  known  method  of 
computation,  but  at  best  it  is  only  approximate,  being  accurate  in 
about  one  case  in  twenty.  But  it  comes  within  a  week  of  being 
correct  in  half  the  cases,  and  within  two  weeks  of  the  date  in 
eighty  per  cent  of  all  pregnancies. 

Another  method  sometimes  employed  by  obstetricians  is  to 
estimate  the  month  to  which  pregnancy  has  advanced  by  meas- 
uring the  height  of  the  fundus,  and  thus  forecasting  tlie  prob- 
able date  of  confinement.  It  is  generally  agreed  that  the  ascent 
of  the  fundus  is  fairly  uniform  and  that  at  the  fourth  month  it 
is  half  way  between  the  symphysis  and  umbilicus;  at  the  sixth 
month,  on  a  level  with  the  umbilicus;  at  the  seventh  month, 
three  fingers'  breadth  above;  at  the  eighth  month,  six  fingers 

03 


94 


OBSTETRICAL  NURSING 


above  the  umbilicus  and  at  the  ninth  month  just  below  the 
xiphoid.  At  the  tenth  month,  or  term,  the  fundus  sinks  down- 
ward to  about  the  position  it  occupied  at  the  eighth  month. 
(Figs.  31,  32  and  33.) 

This  method,  however,  is  measuring  by  months,  not  days,  and 
leaves  a  wide  margin  for  conjecture  as  to  the  exact  date. 


Fig.  31. — Height  of  fundus  at  each  of  the  ten  lunar  months  of  pregnancy. 

Still  another  method  is  to  count  forward  20  or  22  weeks  from 
the  day  upon  which  the  expectant  mother  first  feels  the  fetus 
move.  As  we  shall  see  presently,  this  experience,  termed  ' '  quick- 
ening," usually  occurs  about  the  18th  or  20th  week,  but  is  so 
irregular  that  it  is  unreliable  as  a  basis  for  computation. 

The  possibility  of  estimating  the  date  of  confinement  is  still 
further  complicated  by  the  fact  that  there  is  evidently  consider- 


SYMPTOMS  AND  PHYSIOLOGY  OP  PREGNANCY   95 

able  variation  in  the  length  of  entirely  normal  pregnancies. 
Many  healthy  children  are  born  before  ten  Innar  montlis  liave 
elapsed,  while  more  deliveries  occur  after  than  on  the  expected 
date.  The  first  pregnancy  is  usually  shorter  than  subsequent 
ones,  and  women  who  are  well  nourished  and  well  cared  for  have 
longer  pregnancies,  as  a  rule,  than  those  less  favored. 

Although  the  symptoms  of  pregnancy  have  been  observed 
throughout  the  ages  by  women  who  have  l)()rne  children,  and 
accoucheurs  of  one  sort  and  another  who  have  attended  thern^  a 


Fig.  32. — Contour  of  abdomen 
at  ninth  month  of  pregnancy,  or 
before  the  waistline  drops. 


Fig.  33. — Contour  of  abdomen  at 
tenth  month  of  pregnancy,  or  after 
the  waistline  has  dropped. 


positive  diagnosis  at  an  early  stage  of  this  condition  is  some- 
times still  baffling  to  the  most  experienced  obstetricians. 

So  many  symptoms  of  pregnancy  are  known  to  Avomen  the 
world  over,  that  an  expectant  mother  frequently  recognizes  her 
pregnant  state  at  a  very  early  date.  This  is  particularly  true  of 
women  who  have  previously  borne  children.  But  as  these  same 
symptoms  closely  resemble  those  of  other  conditions,  they  are 
not  infrequently  ascribed  to  impaired  health,  with  the  result  that 
the  pregnancy  is  not  discovered  until  it  is  well  advanced,  and 
then  sometimes  only  by  accident.    And  one  even  hears  of  an  occa- 


96  OBSTETRICAL  NURSING 

sional  case  in  which  a  woman  is  entirely  unaware  of  her  condi- 
tion until  she  goes  into  labor. 

The  converse  is  also  true,  for  women  sometimes  erroneously 
believe  themselves  pregnant  because  of  the  appearance  of  wel} 
recognized  symptoms,  which  are  due  to  other  causes.  This  con- 
dition is  known  as  pseudocyesis,  or  spurious  pregnancy,  and  is 
usually  found  in  women  approaching  the  menopause  or  in  young 
women  who  intensely  desire  offspring.  It  is  a  pathetic  occur- 
ence, and  the  patient  is  usually  so  tenacious  of  her  belief  in  her 
approaching  motherhood  that  the  obstetrician  dispels  it  only 
with  great  difficulty. 

For  all  of  these  and  other  reasons  it  is  customary  to  divide 
the  signs  and  symptoms  of  pregnancy  into  three  groups,  under 
self-explanatory  headings,  namely :  'presumptive  symptoms,  and 
prohalle  and  positive  signs.  Although  it  is  never  within  the 
province  of  a  nurse  to  make  a  diagnosis,  it  is  important  that  she 
be  familiar  with  symptoms.  In  obstetrics  this  seems  to  be  par- 
ticularly true,  and  especially  so  if  the  nurse  be  engaged  in  pre- 
natal work  or  in  any  branch  of  public  health  nursing  that  brings 
her  in  touch  with  possible  or  expectant  motherhood.  The  wider 
her  grasp  of  obstetrical  knowledge,  the  more  helpful  and  reas- 
suring can  be  her  relation  to  her  patient.  To  this  end,  therefore, 
we  will  take  up  the  most  reliable  symptoms  and  signs  of  preg- 
nancy. 

The  presumptive  signs,  which  consist  largely  of  subjective 
symptoms  observed  by  the  patient  herself,  are  as  follows : 

1.  Cessation  of  menstmation.  This  is  usually  the  first  symptom 
noticed.  A  period  may  be  omitted  from  any  one  of  several  causes,  as 
has  been  explained  in  Chap.  II  but  in  a  healthy  woman  of  the  child- 
bearing  age,  whose  menses  have  previously  been  regular,  the  missing 
of  two  successive  periods  after  intercourse  is  a  strong  indication  of 
pregnancy. 

2.  Changes  in  the  breasts.  These  also  occur  early.  The  breasts 
ordinarily  increase  in  size  and  finnness,  and  many  women  complain  of 
throbbing,  tingling  or  pricking  sensations  and  a  feeling  of  tension  and 
fullness.  The  breasts  may  be  so  tender  that  even  slight  pressure  is 
painful.  The  nipples  are  larger  and  more  prominent,  while  both  they 
and  the  surrounding  areolae  grow  darker.  The  veins  under  the  skin 
are  more  apparent  and  the  glands  of  Montgomery  larger.    If  in  addi- 


SYMPTOMS  AND  PHYSIOLOGY  OF  PREGNANCY   97 

tion  to  these  symptoms  it  is  possible  to  express  a  pale  yellowish  fluid 
from  the  nipples  of  a  woman  who  has  not  had  children,  pregnancy  may 
be  strongly  suspected.  But  practically  all  of  these  symptoms  may  be 
due  to  causes  other  than  pregnancy,  and,  in  the  case  of  a  woman  who 
has  borne  childi'en,  milk  may  be  present  in  the  breasts  for  months,  or 
even  years,  after  the  birth  of  a  child. 

3.  "Morning  sickness,"  as  the  name  suggests,  is  nausea,  some- 
times accompanied  by  vomiting,  from  which  many  pregnant  women 
suffer  immediately  upon  arising  in  the  morning.  It  varies  in  severity 
from  a  mild  attack  when  the  patient  first  lifts  her  head  to  repeated  and 
severe  recurrences  during  the  day,  and  even  into  the  night.  More 
frequently,  however,  the  discomfort  passes  off  in  a  few  hours.  When 
the  vomiting  persists,  it  is  termed  "pernicious  vomiting"  and  is  usually 
aceejjted  as  a  possible  symptom  of  a  reHex,*to.\ic  or  neurotic  condition, 
all  of  which  wdll  be  discussed  with  the  complications  of  pregnancy. 
Morning  sickness  may  begin  immediately  after  conception,  but  sets  in 
as  a  rule  about  the  sixth  week  and  continues  until  the  third  or  fourth 
month.  It  occurs  in  about  half  of  all  pregnancies  and  is  particularly 
common  among  women  pregnant  for  the  first  time.  But  on  the  other 
hand,  it  must  be  borne  in  mind  that  many  non-pregnant  women  suffer 
from  nausea  in  the  morning;  many  women  go  throughout  the  entire 
period  of  gestation  without  any  such  disturbance,  while  others  are  en- 
tirely comfortable  in  the  morning  and  nauseated  only  during  the  latter 
part  of  the  day. 

4.  Frequent  micturition.  There  is  usually  a  desire  to  void  urine 
frequently  during  the  first  three  or  four  months  of  pregnancy,  after 
which  the  tendency  disappears,  but  recurs  during  the  later  months. 
The  inclination  may  be  due  in  part  to  nervousness,  but  is  largely  caused 
by  pressure  exerted  by  the  enlarging  uterus  upon  the  bladder,  and  not 
to  any  functional  disturbance  of  the  kidneys,  as  is  sometimes  believed. 
Pressure  on  the  outside  of  the  bladder  gives  much  the  same  sensation 
as  is  experienced  when  the  bladder  is  distended  mth  urine.  After 
the  uterus  rises  from  the  pelvic  cavity  into  the  abdomen,  it  no  longer 
crowds  the  bladder,  until  it  drops  during  the  last  month  or  six  weeks, 
when  it  again  presses  upon  this  organ  and  cause  a  desire  to  void, 

5.  Increased  discoloration  of  the  pigmented  areas  of  the  skin, 
and  also  of  the  mucous  membranes,  is  another  early  symptom  of  preg- 
nancy. In  addition  to  the  deepened  tint  of  the  nipples  and  surround- 
ing areola?,  the  so-called  Imea  nigra  appears  upon  the  abdomen,  ex- 
tending from  the  pubis  toward  the  umbilicus.  There  are  also  the  dark 
bluish  or  purplish  appearance  of  the  vulval  and  vaginal  linings;  the 
yellowish,  irregularly  shaped  blotches  which  sometimes  appear  on  the 
face  and  neck,  known  as  chloasma:  dark  circles  under  the  eyes  and 
the  strice  on  the  abdomen. 


98  OBSTETRICAL  NURSING 

6.  "Quickening"  is  the  widely  used  term  which  designates  the 
mother's  first  perception  of  the  fetal  movements.  It  occurs  about  the 
eighteenth  or  twentieth  week,  and  is  regarded  by  some  obstetricians  as 
a.positive  and  by  others  as  merely  a  strongly  presumptive  sign  of  preg- 
nancy. The  sensation  is  likened  to  a  very  slight  quivering-  or  tapping, 
or  to  the  fluttering  of  a  bird's  wings  imprisoned  in  the  hand.  Begin- 
ning very  gently,  these  movements  increase  in  severity  as  time  goes 
on  until  they  become  very  troublesome  toward  the  latter  part  of  preg- 
nancy, amounting  then  to  sharp  kicks  and  blows.  Women  who  have 
had  children  can  usually  be  relied  upon  to  distinguish  between  quicken- 
ing and  the  somewhat  similar  sensation  caused  by  the  movement  of 
gas  in  the  intestines,  but  a  woman  pregnant  for  the  first  time  may  be 
deceived. 

There  are  many  other  possible  symptoms  of  pregnancy,  but 
their jvalue  is  very  uncertain.  Even  the  ones  described  above  are 
not  entirely  dependable,  but  if  two  or  more  of  them  occur  coin- 
cidently,  they  probably  indicate  pregnancy.  Dr.  Slemons  sums 
it  up  by  saying,  "If,  for  example,  menstruation  has  previously 
been  regular  and  then  a  period  is  missed,  the  patient  has  good 
reason  to  suspect  she  is  pregnant;  if  the  next  period  is  also 
missed  and  meanwhile  the  breasts  have  enlarged,  the  nipples 
darkened,  and  the  secretion  of  colostrum  has  begun,  it  is  nearly 
certain  that  she  is  pregnant ;  whether  morning  sickness  and  the 
desire  to  pass  urine  frequently  are  present  is  of  no  importance. ' '  ^ 

The  probable  signs  of  pregnancy  are  chiefly  discoverable  by 
the  physician  after  careful  examination.  They  also  are  numer- 
ous and  uncertain,  but  there  are  four  which  are  considered  fairly 
trustworthy. 

1.  Enlargement  of  the  abdomen,  which  is  first  in  order  of  im- 
portance, is  apparent  about  the  third  month.  At  this  stage  the  growing 
uterus  may  be  felt  through  the  abdominal  wail  as  a  tumor  which  steadily 
increases  in  size  as  pregnancy  advances.  Rapid  enlargement  of  the 
abdomen  in  a  woman  of  child-bearing  age,  therefore,  may  be  taken  as 
fair,  but  not  positive,  evidence  of  pregnancy.  But  too  much  reliance 
cannot  be  placed  in  this  sign,  as  the  abdomen  may  be  enlarged  by  a 
tumor,  fluid  or  a  rapid  increase  in  fat. 

2.  Changes  in  the  size,  shape  and  consistency  of  the  uterus  which 
take  place  duiing  the  first  three  months  of  pregnancy  are  very  im- 
portant indications.  The.se  arc  discoverable  upon  vaginal  examination, 
which  shows  the  uterus  to  be  more  ante-flexed  than  normal,  considerably 

*  The  Prospective  Mother,  by  J.  Morris  Slemons. 


SYMPTOMS  AND  PHYSIOLOGY  OF  PREGNANCY   99 

enlarged,  somewhat  globular  in  shape  and  of  a  soft,  doughy  consistency. 
About  the  sixth  week  the  so-called  Ilegar's  sign  is  perceptible  through 
bimanual  examination,  the  fingers  of  one  hand  being  pressed  deeply 
into  the  abdomen,  just  above  the  symphysis  and  two  fingers  of  the 
other  hand  passed  through  the  vagina  until  they  rest  in  the  postenor 
fornix,  behind  the  cervix.  The  lower  segment  of  the  uterus,  which  may 
be  felt  between  the  finger  tijjs  of  the  two  hands,  is  extremely  soft  and 
compressible.  This  sign,  named  for  the  man  who  first  described  it, 
is  one  of  the  most  valuable  signs  in  early  pregnancy. 

3.  Softening  of  the  cervix  occurs,  as  a  rule,  about  the  begin- 
ning of  the  second  month.  In  some  cases,  such  as  certain  inflammatory 
conditions  and  in  carcinoma,  this  sign  may  not  appear. 

4.  Painless  uterine  contractions,  called  Braxton  Hicks  from  their 
first  obsei'ver,  begin  during  the  early  weeks  of  pregnancy  and  recur 
at  intervals  of  five  or  ten  minutes  throughout  the  entire  period  of 
gestation.  The  patient  is  not  conscious  of  these  contractions,  but  they 
may  be  observed  during  the  early  months  by  bimanual  examination, 
and  subsequently  by  placing  the  hand  on  the  abdomen.  One  feels 
the  uterus  growing  alternately  hard  and  soft  as  it  contracts  and  relaxes. 

But  all  of  the  probable  signs  of  pregnancy,  like- the  presump- 
tive symptoms,  may  be  simulated  in  non-pre^ant  conditions; 
hence  the  appearance  of  any  one  of  them  alone  may  not  be  deeply 
significant.  But  two  or  more  occurring  coineidently  constitute 
strong  evidence  of  pregnancy. 

The  positive  signs  of  pregnancy,  of  which  there  are  three,  are 
not  apparent  until  the  18th  or  20th  week,  and  all  emanate  from 
the  fetus. 

1.  Hearing  and  counting  the  fetal  heart  beat  is  unmistakable 
evidence  of  pregnancy.  The  sound  of  the  fetal  heart  beat  is  usually 
likened  to  the  ticking  of  a  watch  under  a  jiillow.  The  rate  is  from  120 
to  140  per  minute,  being  about  twice  as  fast  as  the  maternal  pulse. 
So  long  as  its  rhythm  is  regular,  however,  the  rate  may  drop  to  100 
or  increase  to  160  beats  per  minute  without  being  considered  abnonnal, 
or  indicative  of  trouble  with  the  fetus. 

2.  Ability  to  palpate  the  outline  of  the  fetus  is  also  a  positive 
sign  of  pregnancy,  if  the  head,  breech,  back  and  extremities  are  unmis- 
takably made  out  through  the  abdominal  wall. 

3.  Perception  of  active  and  passive  movements  of  the  fetus  is 
accepted  as  a  third  incontrovertible  sign  of  {)regnancy.  There  is  some 
difference  of  opinion  concerning  the  value  of  "quickening"  alone  as  a 
positive  sign  of  pregnancy.  But  if  the  fetal  movements  are  also  per- 
ceptible by  the  obstetrician  through  the  mother's  abdominal  wall  or 


100  OBSTETRICAL  NURSING 

by  vaginal  examination,  there  can  be  no  doubt  about  the  diagnosis. 
The  movements  felt  by  placing  the  hand  upon  the  abdomen  are  termed 
active  movements,  while  the  passive  movements  result  from  internal  or 
external  ballottement.  Ballottement  is  accomplished  by  giving  a  sharp 
or  sudden  push  to  the  head  or  an  extremity,  and  feeling  it  rebound  in 
a  few  seconds  to  its  original  position.  Passive  movements  may  be  felt 
early  in  the  fourth  month,  and  active  movements  after  the  18th  or 
20th  week. 

PHYSIOLOGY  OF  PREGNANCY 

A  general  understanding  of  the  physiology  of  pregnancy  is 
indispensable  to  an  appreciation  of  the  importance  of  observing 
the  present-day  teachings  about  the  hygiene  of  pregnancy.  Upon 
this,  in  turn,  must  rest  intelligently  administered  prenatal  care, 
one  of  the  most  important  branches  of  obstetrics. 

The  physiology  of  pregnancy  really  represents  an  adjustment 
of  the  various  functions  of  the  maternal  organism,  which  are 
altered  to  meet  the  demands  made  upon  the  mother 's  organs  by 
the  body  which  is  developing,  growing  and  functioning  within 
hers.  These  adjustments  are  in  the  nature  of  an  emergency 
service,  since  they  come  into  existence  and  operate  only  while 
needed,  which  is  during  pregnancy,  and  promptly  disappear 
when  the  need  for  them  ceases  with  the  birth  of  the  child.  The 
mother 's  body  then  begins  to  return  to  its  normal,  non-pregnant 
state,  which,  with  the  exception  of  the  breasts,  which  function 
for  nine  or  ten  months,  is  accomplished  in  a  few  weeks. 

But  in  addition  to  the  normal  changes  in  physiology  in  the 
course  of  pregnancy,  there  are  frequently  abnormal  changes,  too, 
which  may  be  symptoms  of  grave  complications.  The  detection 
of  these  symptoms,  and  the  employment  of  treatment  which 
they  indicate,  constitute  one  of  the  most  valuable  aspects  of 
prenatal  care. 

Although,  as  might  be  expected,  the  alterations  in  the  struc- 
ture and  functions  of  the  maternal  organism  are  most  marked 
in  the  generative  organs,  there  are  definite  changes  in  other  and 
remote  parts  of  the  body  as  well.  And  there  are  adjustments  in 
metabolism,  which,  though  not  wholly  understood,  are  now 
widely  recognized  as  important.  It  is  pretty  generally  believed 
that  as  a  direct  result  of  pregnancy,  certain  substances  are  ere- 


SYMPTOMS  AND  PHYSIOLOGY  'OF  FRE<!}MAMCY     101 

ated,  possibly  by  the  corpus  luteum,  which  circulate  in  the  blood 
and  definitely  influence  the  maternal  functions.  It  is  possible 
that  a  development  of  the  present  imperfect  knowledge  of  these 
substances  will  result  ultimately  in  the  discovery  of  a  blood  re- 
action which  will  serve  to  diagnose  pregnancy  in  an  early  stage. 

At  present,  we  know  that,  in  spite  of  the  creation  of  an  in- 
fant body  weighing  upwards  of  seven  pounds,  a  placenta  weigh- 
ing more  than  a  pound,  together  with  an  increase  of  about  two 
pounds  in  the  weight  of  the  uterine  muscle,  all  in  the  short  span 
of  nine  months,  the  expectant  mother  has  to  eat  very  little  more 
during  this  period  than  she  ordinarily  does  to  maintain  her  own 
bodily  functions.  This  suggests  a  highly  developed  economy  in 
the  use  of  nutritive  material  by  maternal  cells. 

We  also  know  that  the  mother  excretes  waste  materials  for 
the  fetus  and  must  assume  that  this  requires  an  increased,  or 
adjusted,  functional  activity  of  her  excretory  organs,  the  skin, 
lungs  and  kidneys.  Moreover,  the  secretory  activity  of  the  pre- 
viously inactive  mammary  glands,  in  spite  of  their  remoteness 
from  the  pelvis,  suggests  a  nervous  or  chemical  stimulation,  or 
both,  which  occurs  only  during  pregnancy. 

The  changes  in  the  uterus  itself,  however,  are  unquestionably 
the  most  marked  that  take  place  during  the  period  of  gestation. 
Those  that  relate  to  the  lining  have  been  described  in  a  previous 
chapter.  The  change  and  growth  in  the  muscle  wall  are  amazing. 
New  muscle  fibres  come  into  existence;  those  already  there  in- 
crease greatly  in  size  and  there  is  a  marked  development  of  con- 
nective tissue. 

The  actual  substance  of  the  uterus  is  so  increased  that  it  is 
converted  from  an  organ  weighing  two  ounces  into  one  weighing 
two  pounds.  From  a  firm,  hard,  thick  walled,  somewhat  flat- 
tened body  in  its  non-pregnant  state,  the  gravid  uterus  assumes 
a  globular  outline  and  grows  so  soft  that  the  fetus  may  be  felt 
through  the  walls. 

During  the  first  few  months  the  uterine  walls  increase  in 
thickness,  but  later  they  grow  progressively  thinner,  until  by  the 
end  of  pregnancy  they  are  only  about  5  millimetres  thick. 

This  early  growth  of  the  uterus  is  doubtless  brought  about 
by  general  systemic  changes  rather  than  by  the  presence  of  the 


102  OBSTETJEliCAL  NURSING 

contained  embryo.  Evidence  of  this  is  found  in  the  case  of  tubal 
pregnancies  when  there  is  a  definite  enlargement  of  the  uterus 
during  the  early  weeks.  After  the  third  month,  however,  the 
growth  of  the  uterus  is  apparently  due  to  pressure  which  the 
growing  fetus  makes  on  the  uterine  walls. 

The  cervix  does  not  enlarge  as  a  result  of  pregnancy,  but  it 
loses  its  hard  cartilaginous  consistency,  becoming  quite  soft,  and 
the  secretion  of  the  cervical  glands  is  much  more  profuse. 

The  changes  in  the  vagina  are  chiefly  due  to  increased  vascu- 
larity. The  blood  vessels  are  actually  larger,  the  products  of  the 
glands  are  greatly  increased  and  the  normal  pinkish  tint  of  the 
mucous  lining  deepens  to  red  or  even  purple. 

The  most  important  changes  in  the  tubes  and  ovaries  is  in 
their  position  because  of  their  being  carried  up  from  the  pelvis 
by  the  enlarging  uterus  into  the  abdominal  cavity.  Although 
they  increase  in  vascularity,  ovulation  is  ordinarily  suspended 
during  pregnancy. 

The  abdomen  as  a  whole  changes  in  contour  as  it  stead- 
ily enlarges,  and  the  skin  and  underlying  muscles  are  somewhat 
affected  as  a  result.  The  tension  upon  the  skin  is  so  great  that 
it  may  rupture  the  underlying  elastic  layers  which  later  atrophy 
and  thus  produce  the  familiar  striw  of  pregnancy,  known  vari- 
ously as  the  strics  gravidarium  and  the  linea  albicantes.  Fresh 
striae  are  pale  pink  or  bluish  in  color,  but  after  delivery  they 
take  on  the  silvery,  glistening  appearance  of  scar  tissue,  which 
they  really  are. 

In  a  woman  who  has  borne  children,  therefore,  we  find  both 
new  and  old  striae ;  those  resulting  from  former  pregnancies  be- 
ing silvery  and  shining,  while  the  fresh  tears  are  pink  or  blue. 
Striae  may  be  found  also  on  the  breasts,  hips  and  upper  part  of 
the  thighs,  and  as  they  are  of  purely  mechanical  origin,  are  not 
necessarily  associated  with  pregnancy  alone.  They  may  result 
from  a  stretching  of  the  skin  by  ascites,  a  marked  increase  in 
fat  or  an  abdominal  tumor. 

The  same  distension  that  causes  striae  sometimes  causes  a 
separation  of  the  recti  muscles.  This  separation,  known  as 
diastasis,  is  sometimes  slight  but  frequently  very  marked,  the 
space  between  the  muscles  being  easily  felt  through  the  thinned 
abdominal  wall. 


SYMPTOMS  AND  PHYSIOLOGY  OF  PREGiNANCY    103 

The  umbilicus  is  deeply  indented  during  about  the  first  three 
months  of  pregnancy.  But  during  the  fourth,  fifth  and  sixth 
months  the  pit  grows  steadily  shallower,  and  by  the  seventh 
month  it  is  level  with  the  surface.  After  this  it  may  protrude, 
in  which  state  it  is  descibed  as  a  "  pouting  umbilicus. ' ' 

The  increased  pigmentation  at  the  umbilicus  and  in  the  me- 
dian line  is  scarcely  to  be  classified  among  the  abdominal 
changes,  as  the  skin  elsewhere  presents  the  same  discolored  ap- 
pearance. The  degree  of  ]Mgnieiitation  varies  with  the  complex- 
ion of  the  individual,  as  blondes  may  be  but  slightly  tinted  while 
the  discolored  areas  on  a  brunette  may  be  dark  brown,  some- 
times almost  black. 

The  changes  in  the  breasts  during  pregnancy  were  practically 
all  included  in  the  enumerated  signs  and  symptoms  of  pregnancy. 
They  increase  in  size  and  firmness  and  become  nodular ;  the  nip- 
ple is  more  prominent  and  together  with  the  surrounding  areola, 
grows'much  darker ;  the  glands  of  Montgomery  are  enlarged ;  the 
superficial  veins  grow  more  prominent,  and  after  the  third  month 
a  thin,  yellowish  fluid  can  be  expressed  from  the  nipples.  This 
fluid,  called  colostrum,  consists  largely  of  fat,  epithelial  cells  and 
colostrum  corpuscles  and  differs  from  milk,  in  its  yellowish  color, 
and  in  the  fact  that  it  coagulates  like  the  white  of  an  egg  when 
boiled.  The  previously  quiescent  mammary  glands  develop  very 
early  in  pregnancy  an  ability  to  select  from  the  blood  stream 
the  necessary  materials  to  produce  a  secretion.  Colostrum  is  the 
product  of  their  activity  until  about  the  third  day  after  delivery, 
when  milk  appears. 

Changes  in  the  cardio-va-scular  system  are  among  those  which 
are  not  altogether  understood,  and  it  is  still  a  moot  question  as 
to  whether  or  not  there  is  an  actual  increase  in  the  amount  of 
maternal  blood  during  pregnancy.  But  results  of  the  most  re- 
cent investigations  suggest  that  there  is  a  definite  increase  in 
both  the  cells  and  the  plasma.  This  increased  amount  circulating 
through  the  heart  subjects  it  to  a  certain  amount  of  strain,  with 
the  result  that  the  organ  is  slightly  hypertrophied  and  the  pulse 
pressure  is  higher. 

The  respiratory  organs  do  not  show  any  marked  alterations. 
The  upward  pressure  of  the  enlarging  uterus  gradually  shortens 
the  height  of  the  thoracic  cavity,  but  if  it  grows  sufficiently  wide 


104  OBSTETRICAL  NURSING 

in  compensation,  there  is  no  decrease  in  the  capacity  of  the 
lungs.  If  this  does  not  occur,  the  patient  may  suffer  from  short- 
ness of  breath.  The  larynx  is  sometimes  reddened  and  edemat- 
ous, a  fact  which  explains  the  damaging  effects  which  child-bear- 
ing may  have  upon  the  voice  of  singers. 

Changes  in  the  digestive  tract  during  pregnancy  are  the 
morning  sickness  already  described,  and  constipation.  The  lat- 
ter is  suffered  by  at  least  one  half  of  all  pregnant  women,  and  is 
due  chiefly  to  pressure  of  the  uterus  on  the  intestines,  though 
impaired  tone  of  the  stretched  abdominal  muscles  may  be  a  fac- 
tor. This  condition  is  most  troublesome  during  the  latter  part 
of  pregnancy.  There  also  may  be  gastric  indigestion  causing 
acidity,  flatulence  and  heartburn,  and  intestinal  indigestion  giv- 
ing rise  to  diarrhea  and  cramp-like  pains.  The  appetite  may  be 
very  capricious  during  the  early  weeks,  and  become  almost  rav- 
enous later  on. 

Changes  in  the  urinary  apparatus  include  frequency  of 
micturition  mentioned  among  the  symptoms  of  pregnancy. 

The  changes  in  the  bony  structures  of  the  pregnant  woman 
are  characterized  by  partial  decalcification.  This  is  accounted  for 
by  the  fact  that  the  developing  fetus  requires  a  definite  amount 
of  calcium  in  the  formation  of  its  osseous  structures,  and  unles? 
the  expectant  mother  absorbs  an  adequate  quantity  from  her 
food,  it  must  be  extracted  from  the  bones  and  similar  structures, 
such  as  the  teeth.  Her  bones  and  teeth  accordingly  grow  softer, 
and  we  have  the  well-known  adage,  "for  every  child  a  tooth," 
as  well  as  the  fact  that  fractures  during  pregnancy  unite  very 
slowly.  There  are  also  the  softened  cartilages  which  were  re- 
ferred to  in  connection  with  the  anatomy  of  the  pelvis.  A  part 
of  the  softening  of  the  pelvic  cartilages,  however,  is  due  to  a 
temporarily  increased  blood  supply.  As  will  be  explained  in  the 
chapter  on  nutrition,  this  partial  decalcification  of  the  mother 
is  entirely  unnecessary,  and  the  newer  knowledge  of  nutrition 
points  the  way  to  its  prevention. 

The  skin  changes  consist  chiefly  in  the  appearance  of  strite 
and  the  increased  pigmentation  to  which  reference  has  already 
been  made.  There  is  also  an  increased  activity  of  the  sebaceous 
and  sweat  glands  and  the  hair  follicles,  the  latter  sometimes  re- 


SYMPTOMS  AND  PHYSIOLOGY  OF  PREGNANCY    105 

suiting  in  the  hair  becoming  much  more  abundant  during  the 
period  of  gestation.  Although  the  pigmented  areas  on  the 
breasts  and  abdomen  never  quite  return  to  their  original  bue, 
the  chloasmata,  sometimes  called  the  "masque  des  femmes  en- 
ceintes," practically  alwaj's  disappear  and  leave  no  trace,  a  fact 
that  is  frequently  a  comfort  to  an  expectant  mother. 

The  carriage  is  somowliat  affected  during  pregnancy  because 
the  increased  size  and  weight  of  the  abdominal  tumor  shifts  the 
centre  of  gravity.  In  an  effort  to  preserve  an  upright  position 
the  woman  throws  back  her  head  and  shoulders  and  finally  as- 
sumes a  gait  that  may  be  described  as  a  waddle,  particularly 
noticeable  in  short  women. 

Temperature  changes  are  probably  not  caused  by  pregnancy 
per  se,  though  some  authorities  believe  that  there  is  normally  a 
slight  elevation  during  the  latter  part  of  the  day. 

Mental  and  emotional  changes  are  usually  included  among 
the  alterations  which  occur  during  pregnancy,  but  the  present 
status  of  psychiatry  suggests  that  this  may  not  be  altogether  true. 
It  is  a  fact  that  many  pregnant  women  show  marked  mental  and 
emotional  unbalance,  but  as  yet  there  seems  to  be  no  evidence 
that  these  states  are  inherently  due  to  pregnancy,  though  the 
same  condition  may  recur  in  the  same  woman  each  time  that  she 
is  pregnant. 

"We  shall  consider  this  important  subject  more  at  length  in 
the  chapter  on  mental  hygiene,  so  it  may  be  enough  simply  to 
say  at  this  juncture  that,  in  a  sensitively  strung  or  uncertainly 
poised  woman,  the  state  of  being  pregnant  may  be  merely  the 
last  straw,  so  to  speak,  that  upsets  her  equilibrium ;  and  that 
some  other  experience,  which  would  be  an  equal  strain  upon  her 
slender  ability  to  make  adjustments,  would  result  in  exactly  the 
same  mental  or  emotional  distortion,  just  as  certain  physical 
signs  in  pregnancy  may  be  produced  also  in  the  non-pregnant 
state,  and  are  not,  therefore,  necessarily  inherent  to  the  gravid 
state. 

Changes  in  the  ductless  glands  are  in  much  the  same  cate- 
gory. Functional  disturbances  of  these  glands  occurring  at  any 
time  may  give  rise  to  great  irritability,  excitability  or  to  other 
mental  symptoms.     A  non-pregnant  woman  with  even  a  very 


106  OBSTETRICAL  NURSING 

slight  degree  of  hyperthyroidism,  for  example,  may  be  noticeably 
unstable  mentally  or  emotionally.  Since  there  is  evidently  an 
inter-relation  and  inter-dependence  of  the  functions  of  the  duct- 
less glands,  and  since  ovulation,  the  function  of  one  of  these 
glands,  is  suspended  during  pregnancy,  we  can  readily  believe 
that  other  glands  would  undergo  changes  as  a  result.  Alterations 
in  the  thyroid  are  particularly  apparent  as  it  becomes  enlarged 
and  more  active  in  the  majority  of  pregnant  women,  as  does  also 
the  anterior  lobe  of  the  pituitary  body.  This  increased  activity 
may  tend  to  compensate  for  the  suspended  function  of  the 
ovaries.  But  the  alterations  in  the  functions  of  the  other  glands, 
compensatory  though  they  be  in  part,  apparently  produce  much 
the  same  sort  of  nervous  symptoms  that  they  are  capable  of  pro- 
ducing in  a  non-pregnant  woman. 

Taking  the  condition  as  a  whole,  pregnancy  is  usually  char- 
acterized by  an  improved  state  of  health.  During  the  first  few 
months  there  may  be  lassitude  and  loss  of  weight,  but  the  latter 
part  of  the  period  is  notable  for  an  unusual  degree  of  general  well 
being  and  for  an  increase  in  flesh  over  the  entire  body,  which 
may  amount  to  as  much  as  twenty -five  or  thirty  pounds. 

About  fifteen  pounds  of  the  increased  weight  is  lost  at  the 
time  of  labor  and  a  still  further  reduction  occurs  during  the  suc- 
ceeding weeks  when  the  mother's  body  returns  approximately 
to  its  original  condition.  But  it  sometimes  happens  that  the 
improved  state  of  nutrition  acquired  during  pregnancy  becomes 
permanent. 


There  was  a  time  when  you  were  not. 

You  merry  sprite,  save  as  a  strain, 

The  strange  dull  pain 

Of  green  buds  swelling 

In  warm,  straight  dwelling 

That  must  burst  to  the  April  rain. 

A  little  heavy  I  was  then 

And  dull — and  glad  to  rest.    And  when 

The  travail  came 

In  searing  flame  .  .  . 

But,  sprite,  that  was  so  long  ago ! — 

A  century ! — I  scarcely  know. 

Almost  I  had  forgot 

When  you  were  not. 

— Eunice  Tietjens. 


PART  III 
The  Expectant  Mother 

CHAPTER  VI.  PRENATAL  CARE.  Instruction  of  the  Mother,  Exami- 
nations, and  Observations.  Importance  of  Prenatal  Care.  The 
Nurse 's  Part.  Personal  Hygiene  of  Pregnancy.  Excretions.  Kid- 
neys. Urine  Tests.  Skin.  Bowels.  Clothes:  corsets,  binders,  shoes. 
Diet.  Fresh  Air  and  Exercise.  Rest  and  Sleep.  Care  of  the  Breasts. 
Teeth.  Travelling.  Marital  Relation.  Common  Discomforts  during 
Pregnancy.  Nausea  and  Vomiting.  Heartburn.  Distress.  Flatu- 
lence. Diarrhea.  Pressure  Symptoms.  Swelling  of  the  Feet.  Vari- 
cose Veins.  Hemorrhoids.  Cramps  in  the  Legs.  Shortness  of  Breath. 
Vaginal  Discharge.  Itching.  Early  Symptoms  of  Complications  of 
Pregnancy:      Toxemias,  Premature  Terminations,   Hemorrhage. 

CHAPTER  VII.  MENTAL  HYGIENE  OF  THE  EXPECTANT 
MOTHER.  Common  Causes  of  Mental  and  Nervous  Breakdown 
during  Pregnancy.     Nurse 's  Attitude. 

CHAPTER  VIII.  PREPARATION  OF  ROOM,  DRESSINGS  AND 
EQUIPMENT  FOR  HOME  DELIVERY. 

CHAPTER  IX.  COMPLICATIONS  AND  ACCIDENTS  OF  PREG- 
NANCY. Premature  Terminations  of  Pregnancy.  Definition  of 
Terms.  Abortions.  Causes:  Abnormalities  of  Fetus;  Abnormalities 
in  the  Generative  Tract;  Acute  Infectious  Diseases;  Mental  or  Emo- 
tional Stress;  Physical  Shocks.  Premonitory  Symptoms.  Prevention, 
Treatment,  and  Nursing  Care  of  Threatened,  Incomplete,  and  Com- 
plete Abortions.  Missed  Abortion.  Therapeutic  Abortion.  Clerical 
and  Legal  Aspects  of  Abortion.  Criminal  Abortion.  Premature 
Labor:  Causes,  Treatment  and  Nursing  Care.  Ante-partum  Hemor- 
rhage. Placenta  Praevia:  Cause,  Symptoms,  Treatment  and  Nursing 
Care.  Premature  Sei)aration  of  a  Normally  Implanted  Placenta : 
Cause,  Symptoms,  Treatment  and  Nursing  Care.  To.xemias  of 
Pregnancy.  Pernicious  Vomiting  of  Pregnancy.  Symptoms,  Treat- 
ment and  Nursing  Care  of  Reflex  Vomiting,  Neurotic  Vomiting, 
Toxemic  Vomiting.  Pre-eclamptic  Toxemia :  Symptoms,  Prevention, 
Treatment  and  Nursing  Care.  Eclampsia:  Symptoms,  Treatment 
and  Nursing  Care.  Nephritic  Toxemia:  Cause,  Symptoms,  Treat- 
ment and  Nursing  Care.  Acute  Yellow  Atrophy  of  the  Liver: 
Cause,  Symptoms,  Treatment  and  Nursing  Care.  Other  Important 
Complications  of  Pregnancy:  Syphilis.  Heart  Lesions.  Pulmo- 
nary Tuberculosis.     Thyroidism.     Pyelitis.     Gonorrhea. 


CHAPTER   VI 
PRENATAL  CARE 

The  day  is  long  since  past  when  the  obstetrician's  concern  for 
his  patient  began  when  she  went  into  labor.  The  obstetrician  of 
to-day  watches  and  cares  for  his  patient  throughout  pregnancy, 
for  he  knows  that  by  so  doing  he  greatly  increases  her  chances 
of  surviving  the  ordeal  of  childbirth,  and  the  baby's  prospect  of 
living  through  that  perilous  first  year. 

Although  many  conditions  that  result  in  invalidism  or  death 
occur  during  labor  or  the  puerperium,  they  have  their  begin- 
nings during  pregnancy.  Their  prevention,  then,  or  early  recog- 
nition, followed  by  prompt  and  efficient  treatment,  will  avert 
many  of  the  dreaded  complications  and  emergencies  associated 
with  childbearing. 

In  order  to  prevent  these  disasters  it  is  necessary  to  super- 
vise the  expectant  mother  and  care  for  her  from  early  in  preg- 
nancy— from  the  time  of  conception  if  possible — until  the  onset 
of  labor,  and  this  is  prenatal  care.  It  may  be  divided  into  in- 
struction, examinations  and  observations,  as  follows : 

1.  a.  Teaching  the  expectant  mother  the  principles  of  personal 
hygiene,  as  especially  adapted  to  meet  her  needs,  and  helping  her  to 
adopt  them; 

b.  Describing  to  her  the  more  apparent,  normal  changes  of  preg- 
nancy which  she  is  likely  to  notice  and  perhaps  not  understand,  and 
also  the  common  symptoms  of  complications  which  she  may  detect  and 
should  report; 

2.  The  doctor's  preliminaiy  examination,  early  in  pregnancy,  com- 
prising a  study  of  the  size,  shape  and  proportions  of  the  pelvis,  and 
later  their  relation  to  the  size  and  mouldability  of  the  baby's  head;  a 
Wassermann  test  for  syphilis;  urinalysis  and  measuring  the  blood  pres- 
sure. In  addition  to  these,  a  complete  physical  survey  is  made,  con- 
sisting of  examinations  of  the  heart,  lungs,  breasts,  abdomen,  a  vaginal 
smear  for  gonorrhea,  and  the  patient's  height,  weight  and  temperature; 

3.  Constant   watching  for  early   symptoms   of  the  complications 

111 


112  OBSTETRIC  AJj  NURSING 

of  pregnancy,  with  speedy  treatment  of  such  symptoms  when  they 
appear,  and  relieving  the  common  discomforts  of  pregnancy;  making 
observations  upon  the  presentation  and  size  of  the  fetus,  later  in  preg- 
nancy, in  order  to  plan  ahead  of  time  for  the  delivery,  if  the  patient's 
condition  makes  this  advisable. 

Prenatal  care  of  this  character  is  essentially  preventive  for 
both  the  mother  and  the  new-born  baby. 

We  gain  a  faint  impression  of  what  it  may  prevent  when  we 
learn  that  year  after  year,  about  17,000  young  women  die 
in  the  United  States  from  causes  associated  with  childbirth, 
which  are  known  to  be  largely  preventable  (during  1918  the 
number  was  23,000)  ;  and  that  each  year  about  112,000  babies 
are  born  dead,  and  100,000  of  those  born  alive  perish  during  the 
first  month  of  life,  also  from  causes  which  are  largely  con- 
trollable. 

But  17,000  dead  mothers  and  200,000  dead  babies,  most  of 
whom  might  have  lived,  are  not  all  that  enter  into  the  annual 
erection  of  this  national  monument  to  neglect.  There  are  also 
the  unrecorded  and  uncounted  victims  of  little  or  no  obstetrical 
care  who  have  had  too  much  vigor  to  succumb  completely  and  die, 
and  who,  therefore,  live  on  through  years  of  wretched  invalidism. 
Sometimes,  it  is  true,  their  disability  is  slight,  so  slight  as  to  be 
uninteresting,  and  of  no  statistical  importance.  But  to  the  wo- 
man herself,  who  must  resume  the  functions  of  mother,  home- 
maker,  wife  and  general  utility  person,  the  disability  may  be 
enough  to  make  life  endlessly  dreary  and  discouraging.  And 
yet,  she  is  perhaps  only  just  below  the  physical  level  upon  which 
she  could  live  her  life  with  joy  and  eagerness;  and  proper  care 
when  the  baby  came  would  have  left  her  upon  that  level. 

The  effect  of  the  mother's  impairment  reaches  far  beyond  her 
own  invalidism,  for  such  women  are  not  as  well  able  to  rear  and 
care  for  their  children  satisfactorily  as  are  fresh,  buoyant 
mothers.  Whatever  makes  for  good  obstetrics,  therefore,  makes 
for  a  better  race,  and,  as  we  shall  see  later,  measures  that  tend 
to  improve  the  health  of  the  race  tend  to  lessen  the  hazards  of 
ehildbearing. 

Ideal  prenatal  care,  then,  would  really  begin  during  the  ex- 
pectant mother 's  own  infancy,  but  we  must  be  content  here  with 


PRENATAL  CARE  113 

a  description  of  the  care  that  is  advisable,  and  desired,  for  ex- 
pectant mothers  from  the  beginning  of  pregnancy. 

There  is  considerable  difference  of  opinion  among  physicians 
concerning  the  stage  of  pregnancy  at  which  it  is  desirable  to  see 
the  expectant  mother  for  the  first  time,  and  the  frequency  of 
subsequent  observations.  But  the  growing  tendency  is  for  the 
doctor  to  see  his  patient  as  early  as  possible,  for  the  preliminary 
examination,  and  to  follow  a  fairly  uniform  routine  in  the  kind 
and  frequency  of  subsequent  observations,  and  in  the  personal 
hygiene  which  the  patient  is  advised  to  adopt. 

Thus,  it  has  become  generally  customary  to  see  the  patient, 
take  her  temperature,  pulse  and  blood  pressure  and  make  a  urin- 
alysis once  a  month  during  the  first  half  of  pregnancy,  and  then 
every  two  weeks  until  the  onset  of  labor,  or  possibly  once  a  week 
toward  the  end.  These  periodic  examinations  keep  the  physi- 
cian constantly  informed  about  his  patient's  condition,  and  fre- 
quently disclose  very  early  symptoms  of  a  complication  which 
is  easily  amenable  to  treatment  at  that  stage,  but  which  might 
prove  serious  if  allowed  to  progress  unchecked.  Albumen  in  the 
urine,  for  example,  or  an  increase  in  the  blood  pressure,  in  a 
woman  who  had  no  other  sjTuptoms,  would  suggest  the  advisabil- 
ity of  watching  for  further  symptoms  of  toxemia ;  while  an  ele- 
vation of  temperature,  even  though  the  patient  was  not  uncom- 
fortable, might  lead  to  the  early  discovery  of  tuberculosis, 
pyelitis  or  some  other  infection  not  otherwise  apparent. 

(it  is  this  stitch  in  time  that  means  so  much  to  the  pregnant 
woman  and  her  expected  baby. 

But  the  most  painstaking  obstetrician  requires  the  co-opera- 
tion of  his  patient  in  innumerable  little  waj's,  if  she  is  to  have 
the  fullest  benefits  of  his  skill;  for  it  is  not  so  much  what  the 
doctor  advises  that  counts  as  how  the  patient  lives. 

It  is  at  this  point  that  nurses  are  more  and  more  being  given 
opportunity  for  immensely  gratifying  service.  A  private  pa- 
tient who  is  in  the  care  of  an  obstetrician  is,  of  course,  super- 
vised and  instructed  by  her  doctor.  But  there  are  other  patients 
— women  who  cannot  afford  this  individual  care,  but  who  need 
care  none  the  less.  And  it  is  these  expectant  mothers  that  nurses 
are  helping  the  doctors  to  instruct  in  the  principles  of  right  liv 


114  OBSTETRICAL  NURSING 

ing,  and  are  watching  for  danger  signs,  through  visiting  nurse 
societies,  out-patient  departments  of  hospitals  and  through  pre- 
natal clinics. 

The  character  and  extent  of  the  instruction  and  supervision 
given  by  the  nurses  is,  of  course,  decided  by  the  medical  board 
of  her  organization,  and  is  often  affected  by  the  conditions  under 
which  the  work  is  conducted.  The  nurses  in  a  rural  community, 
for  example,  may  take  blood  pressures  and  test  urine  for  albu- 
men, while  in  cities,  rich  in  doctors  and  medical  institutions, 
these  observations  might  not  be  among  their  duties. 

In  addition  to  this  definite  relation  to  expectant  mothers, 
nurses  are  meeting  them,  unofficially  and  informally,  at  every 
turn;  women  who  are  needing,  but  not  receiving,  care  from  a 
doctor  or  an  organization ;  women  who  are  puzzled  or  troubled 
over  their  condition,  but  do  not  know  where  nor  how  to  obtain 
advice ;  women  who  could  employ  a  physician  but  do  not  appre- 
ciate the  importance  of  his  care. 

Every  nurse  should  recognize  it  as  her  duty  to  advise  an  un- 
supervised, pregnant  woman  to  place  herself  under  medical  care, 
no  matter  under  what  conditions  she  meets  her. 

In  the  discharge  of  her  duties,  the  nurse  will  sometimes  need 
no  little  ingenuity  to  adapt  the  routines  of  prenatal  care,  as 
prescribed  by  her  organization,  to  the  mentality,  traditions  and 
varied  demands  of  the  daily  lives  of  her  patients.  But  this  w411 
have  to  be  done,  for  though  in  a  general  way  the  needs  of  all  ex- 
pectant mothers  are  the  same,  their  circumstances  and  personali- 
ties are  infinitely  varied. 

It  may  require  undreamed-of  tact  and  resourcefulness  to  con- 
vince a  patient  that  details  of  care,  which  seem  wholly  unrelated 
to  her  or  her  baby 's  welfare,  will  actually  increase  their  chances 
for  life  and  health.  For  this  reason,  it  is  of  almost  prime  im- 
portance that  the  nurse  win  her  patient's  friendship  and  confi- 
dence. She  will  then  scarcely  realize  that  she  is  being  taught, 
but  will  do  and  continue  to  do  as  she  is  advised,  because  of  an 
almost  insensible  reliance  upon  the  judgment  and  sincerity  of 
her  counsellors. 

It  is  not  the  single  examination  of  a  specimen  of  urine  that 
counts,  nor  the  exercise  taken  with  pleasure  and  enthusiasm 


PRENATAL  CARE  115 

during  the  first  few  days  of  its  novelty.  It  is  not  the  rest,  fresh 
air  nor  proper  food,  taken  according  to  rule  for  a  week  or  two, 
that  will  keep  her  fit.  It  is  the  aggregate  and  repetition  of  the 
infinite  number  of  details  that  make  up  the  expectant  mother's 
mental  and  physical  life  during  twenty-four  hours  in  each  day, 
seven  days  a  week,  throughout  forty  long  weeks,  that  grow 
longer  and  more  monotonous  as  pregnancy  advances ;  it  is  the  mo- 
saic that  she  makes  out  of  the  minutiae  of  her  daily  life  that 
counts.  And  paradoxical  as  it  seems,  she  must  shape  her  days 
to  meet  her  own  and  her  baby's  needs  with  such  steady  per- 
sistence that  she  finally  lives  them  almost  unconsciously  of  what 
she  is  doing,  and  also  without  introspection. 

Obviously,  then,  the  expectant  mother's  mental  attitude  is  of 
considerable  importance. 

She  should  in  general  continue  the  diversions,  work  and 
amusements  that  she  is  accustomed  to  and  enjoys,  if  they  are 
not  contra-indicated ;  cultivate  a  cheerful,  hopeful  frame  of 
mind;  guard  against  being  self-centred  and  over  watchful  of 
symptoms,  and  at  the  same  time  not  adopt  the  dangerous  habit 
of  uncomplainingly  ascribing  to  pregnancy  all  of  the  discomforts 
and  unfamiliar  conditions  which  may  arise.  In  short,  to  forget 
that  she  is  pregnant  in  so  far  as  that  is  consistent  with  the  care 
that  she  should  take  of  herself. 

She  should  understand  that  childbearing  is  a  normal  func- 
tion, but,  like  other  normal  functions,  may  become  abnormal  if 
neglected ;  and  that  a  sick  pregnancy  is  not  a  normal  one. 

In  connection  with  the  patient's  mental  attitude  and  her 
anxieties,  the  nurse  may  be  of  great  comfort  in  helping  to  dispel 
superstitions  and  the  widely  credited  and  depressing  beliefs 
concerning  maternal  impressions. 

After  one  has  traced  the  development  of  the  human  body  in 
the  uterus,  and  even  faintly  understood  its  growth  and  method 
of  nourishment,  it  is  impossible  to  believe  that  the  mother's 
thoughts  or  experiences  could  in  any  way  deform  or  mark  her 
child,  or  alter  its  sex.  That  the  mother's  "reaching  up,"  for  ex- 
ample, could  slip  the  cord  around  the  unborn  baby's  neck  is 
manifestly  absurd,  as  well  as  the  previously  mentioned  supersti- 
tions about  the  eight-month  baby 's  slender  chances  for  survival. 


116  OBSTETRICAL  NURSING 

But  superstitions  are  always  fondly  cherished,  for,  as  Gib- 
bon tells  us,  "the  practise  of  superstition  is  so  congenial  to  the 
multitude,  that  if  they  are  forcibly  awakened,  they  still  regret 
the  loss  of  their  pleasing  vision. ' '  We  can  scarcely  wonder  how- 
ever that  even  intelligent  and  educated  people  hold  utterly  im- 
probable beliefs  about  pregnancy,  for  the  most  fanciful  of  them 
are  quite  as  easy  to  believe  as  the  thing  that  we  know  actually 
occurs — the  development  of  a  human  body  from  a  single  cell. 

These  fanciful  beliefs,  however,  are  sometimes  serious  mat- 
ters to  the  young  woman  who  is  traveling,  day  by  day,  toward  a 
great  and  mysterious  event,  and  they  should  not  be  laughed  to 
scorn,  but  explained  away  seriously  and  with  sympathy.  She 
may  be  told  quite  simply,  that  after  conception  she  gives  her  baby 
only  nourishment;  that  the  baby's  connection  with  her  body  is 
through  the  cord  and  placenta,  in  neither  of  which  are  there 
nerves;  and  that  even  if  the  blood  could  carry  mental  and 
nervous  impulses,  which  it  cannot,  the  maternal  and  fetal  blood 
never  come  in  actual  contact  with  each  other.  A  tale  which  she 
has  heard  about  a  woman  who  saw  something  distressing  and 
later  gave  birth  to  a  marked  child  may  cease  to  worry  her  if 
she  is  reminded  of  the  innumerable  babies,  beautiful  and  un- 
marked, which  are  born  to  women  who  have  had  equally  shock- 
ing experiences.  It  is  scarcely  probable  that  any  woman  lives 
through  the  ten  months  of  pregnancy  without  seeing,  hearing 
or  thinking  things  that  would  disfigure  a  baby  if  maternal  im- 
pressions could  produce  such  results,  and  yet  newborn  babies 
are  very  rarely  blemished.  Although  the  ultimate  causes  of 
marks  and  deformities  of  the  fetus  are  not  definitely  known, 
they  are  probably  to  be  found  in  faulty  development  very  early 
in  the  embryonic  life,  and,  therefore,  are  not  preventable. 

,  HYGIENE  OF  PREGNANCY 

i  In  coming  to  the  expectant  mother's  personal  hygiene,  we 
*  find  that  an  understanding  of  the  physiology  of  pregnancy  al- 
most of  itself  indicates  what  this  hygiene  should  include.  We 
shall  take  it  up  in  detail,  however,  and  describe  what  is  at  pres- 
ent considered  a  reasonable  outline  of  the  routine  desired  for  the 
average  pregnant  woman,  who  is  found  by  careful  examination 


'  PRENATAL  CARE  117 

to  be  normal  and  free  from  complications,  and  needing  only  to 
keep  well.  But,  as  has  been  said,  and  must  be  oft  repeated,  the 
ideal  routine  cannot  be  deposited  en  bloc  upon  all  expectant 
mothers.  It  must  be  adjusted 'to  the  individual  and  to  her  cir- 
cumstances. 

Excretions.  Although,  as  has  been  explained  previously,  the 
pregnant  woman  does  not  have  to  eat  for  two,  she  does  have  to 
eliminate  the  waste  and  broken-down  products  from  two  bodies, 
through  her  own  excretory  organs :  the  kidneys,  skin,  lungs  and 
bowels.  True,  the  amount  of  the  baby's  ash  is  not  great,  but  is 
of  such  a  character  that  its  elimination  is  important  and  in- 
creases the  strain  upon  the  maternal  excretory  apparatus. 

Kidneys.  One  of  the  most  important  factors  in  prenatal 
care  is  promoting  the  function  of  the  kidneys  and  watching  their 
output.  It  is  probably  more  true  of  the  kidneys  than  of  any 
other  organs  that  a  slight  abnormality  which  would  not  give 
trouble  at  other  times  may,  if  neglected  during  pregnancy,  pro- 
duce very  grave  results.  The  amount  of  urine  passed  in  twenty- 
four  hours  should  be  measured,  and  a  specimen  prepared,  once 
a  month  during  the  first  half  of  pregnancy  and  every  tw^o  weeks 
afterward.  If  less  than  three  pints  are  passed  the  patient  should 
know,  without  further  instruction,  that  she  is  not  taking  enough 
water  and  must  take  more.  And  so  it  is  the  nurse's  duty,  in  this 
connection,  to  convince  her  patient  of  the  importance  of  drink- 
ing an  abundance  of  water,  and  periodically  measuring  her  urine 
and  sending  specimens  to  the  doctor  for  examination. 

She  is  very  likely  to  follow  such  advice  if  she  is  told  that  by 
so  doing  she  will  help  to  prevent  convulsions,  for  most  women 
know  of  this  complication  and  dread  it. 

In  preparing  a  specimen,  a  covered  or  corked  receptacle  which 
is  large  enough  to  hold  the  voidings  for  twenty-four  hours,  must 
be  thoroughly  washed  and  scalded ;  in  it  should  be  collected  the 
total  amount  of  urine  voided  during  twenty-four  hours  and  kept 
in  a  place  that  is  cool  enough  to  prevent  putrefactive  changes. 
The  additional  precaution  of  putting  a  teaspoonful  of  chloroform 
into  the  receptacle  is  wise  and  does  not  injure  the  specimen. 
The  patient  should  be  instructed  to  empty  her  bladder  at  any 
designated  hour,  and  then  keep  all  urine  voided  from  that  time 


118  OBSTETRICAL  NURSING 

until  the  corresponding  hour  on  the  following  day.  The  urine 
should  be  shaken  so  as  to  mix  thoroughly  the  different  voidings, 
and  six  or  eight  ounces  poured  into  a  bottle  which  has  been 
washed  and  scalded,  carefully  corked  and  labelled  with  the  date, 
patient's  name,  address  and  the  total  amount  for  twenty-four 
hours. 

If  the  nurse  is  called  upon  to  test  for  albumen,  either  of  the 
following  will  serve,  unless  the  doctor  specifies  a  test  which  he 
prefers : 

Heat  and  acetic  acid  test:  Fill  a  test  tube  about  half  full  of 
urine  and  gently  boil  the  upper  part  in  a  flame ;  add  five  drops  of 
2%  to  5%  acetic  acid  and  again  boil  gently.  The  presence  of 
albumen  is  shown  by  a  white  cloud  in  the  upper  part  of  the  urine. 

Eshach's  test:  Fill  a  test  tube  half  full  of  urine;  add  eight 
or  ten  drops  of  Esbach's  Solution.  The  presence  of  albumen  is 
shown  by  a  white  flocculent  precipitate  in  the  upper  part  of  the 
urine. 

Skin.  Under  ordinary  conditions,  the  skin  serves  as  a  pro- 
tective covering  for  the  body,  helps  to  regulate  the  body  tempera- 
ture and  acts  constantly  as  an  excretory  organ.  This  last  func- 
tion is  performed  by  the  sweat  glands  which  open  upon  the  sur- 
face of  the  body,  and  we  are  told  that  there  are  some  twenty-eight 
miles  of  these  minute,  tube-like  structures  in  the  skin.  These 
glands  should  be,  and  usually  are,  constantly  active  and  they 
daily  pour  upon  the  surface  of  the  body  an  oily  substance  that 
lubricates  the  skin  and  something  over  a  pint  of  water  contain- 
ing waste  matter,  that  is  inimical  to  health  if  retained  in  the 
body.  We  are  not  aware  of  this  constant  excretion  of  fluids, 
which,  therefore,  is  termed  "insensible  perspiration,"  but  it  con- 
tinues even  in  cold  weather  and  must  not  be  interrupted  if  health 
is  to  be  preserved.  If  the  oil,  dust,  particles  of  dead  skin  and 
the  waste  material  left  by  dried  perspiration  are  allowed  to  re- 
main upon  the  surface  of  the  body,  they  will  clog  the  pores  and 
gland  openings  and  thus  interfere  with  their  functions.  The  re- 
moval of  this  material,  then,  is  an  imperative  health  measure. 
This  is  done  automatically,  in  part,  for  the  fluid  evaporates,  and 
much  of  the  solid  matter  is  rubbed  off  on  the  clothing.  But  the 
most  important  aids  to  the  skin's  activity  are  the  drinking  of 


PRENATAL  CARE  119 

plenty  of  water,  deep  breathing,  exercise  and  warm  baths ;  baths 
serving  the  doiiljle  purpose  of  removing  waste  matter  already 
on  the  surface,  and  stimulating  the  glands  to  increased  activity 
in  giving  off  still  more. 

This  explains  the  importance  to  the  expectant  mother  of  thor- 
ough and  regular  bathing,  and  of  keeping  her  body  evenly  warm. 
Most  doctors  advise  a  warm,  not  hot,  shower  or  tub  bath  every 
day,  with  soap  used  freely  over  the  entire  body,  followed  by  a 
brisk  rub.  The  best  time  for  this  warm,  cleansing  bath,  as  a  rule, 
is  just  before  retiring,  as  it  is  soothing  and  restful  and  tends  to 
induce  sleep.  Very  hot  baths  are  fatiguing,  particularly  during 
pregnancy,  and  should  never  be  taken  except  with  the  doctor's 
permission ;  but  cold  baths  usually  may  be  continued  throughout 
pregnancy  if  the  patient  is  accustomed  to  them  and  reacts  well 
afterwards.  Under  these  conditions  the  morning  cold  plunge, 
shower  or  sponge  is  beneficial,  as  it  stimulates  the  circulation  and 
thus  promotes  the  activity  of  the  skin.  Some  doctors  forbid  tub 
bathing  of  any  kind  after  the  seventh  month,  on  the  ground 
that  as  the  patient  sits  in  the  tub  her  vagina  is  filled  with  water, 
which  may  contain  infective  material.  Should  labor  occur 
shortly  afterward  an  infection  might  result.  As  the  patient  is 
heavy  and  somewhat  uncertain  on  her  feet,  there  is  also  the 
danger  of  her  slipping  and  falling  while  getting  in  or  out  of  the 
tub. 

Other  doctors  permit  tub  baths  throughout  pregnancy,  up 
until  the  onset  of  labor;  while  as  to  hot  foot  baths,  there  seems 
to  be  no  reason  for  or  against  them  at  any  time  during  the  nine 
months. 

Bathing  in  a  quiet  stream  or  lake  is  apparently  harmless,  but 
sea  bathing,  if  the  surf  is  rough,  is  inadvisable  because  of  the  im- 
pact of  the  waves  upon  the  abdomen  and  the  general  violence  of 
the  exercise. 

The  importance  of  keeping  the  body  evenly  warm  throughout 
pregnancy  cannot  be  overemphasized,  for  a  sudden  chilling  or 
wetting  may  so  check  the  excretory  function  of  the  skin  as  to 
throw  a  greater  burden  upon  the  kidneys  than  they  can  meet, 
in  their  effort  to  eliminate  the  skin's  share  of  the  body  waste. 
Accordingly,  a  single  chilling  will  sometimes  be  enough  to  pre- 


120  OBSTETRICAL  NURSING 

cipitate  an  eclamptic  seizure.  This  may  be  one  reason  why  we 
see  eclampsia  more  frequently  during  cold  weather  or  after  a 
sudden  drop  in  the  temperature  after  warm  or  mild  days. 

Bowels.  The  bowels,  also,  eliminate  a  certain  amount  of 
toxic  material  and  if  they  do  not  move  thoroughly  at  least  once 
a  day,  deleterious  substances  are  absorbed  into  the  system  and 
an  extra  tax  is  placed  upon  the  kidneys  in  an  attempt  to  excrete 
them. 

Unhappily,  a  large  proportion  of  pregnant  women  suffer  from 
constipation,  particularly  during  the  later  weeks,  though  women 
who  have  always  had  a  tendency  of  this  kind  may  have  trouble 
from  the  very  beginning  of  pregnancy.  Sluggish  peristalsis,  due 
to  pressure  by  the  enlarged  uterus  upon  the  intestines,  is  prob- 
ably the  prime  cause,  though  impaired  tone  of  the  stretched  ab- 
dominal muscles  also  may  be  a  factor. 

The  bowels  should  move  regularly  every  day,  and  to  this  end 
the  patient  should  regularly  attempt  to  empty  them,  immediately 
after  breakfast  usually  being  the  best  time.  The  importance  of 
regularity  in  making  the  attempt  cannot  be  overemphasized,  even 
though  the  bowels  do  not  always  move. 

Exercise,  the  intake  of  an  abundance  of  fluids,  eating  fresh 
fruit,  coarse  vegetables  and  bulky  cereals,  such  as  bran,  to  stim- 
ulate peristalsis,  and  drinking  a  glass  of  hot  or  cold  water  upon 
retiring  and  arising  are  all  laxative  in  their  effect.  As  the  regu- 
lar use  of  enemata  only  tends  to  lessen  intestinal  tone,  they  should 
not  be  employed  unless  ordered  by  the  doctor;  nor  should  the 
patient  take  cathartics  without  the  doctor 's  order.  But  she  may 
safely  increase  the  amount  of  her  fluids  and  the  bulk  of  her  food, 
in  order  to  regulate  her  bowels,  and  may  also  take  senna  and 
prunes  cooked  together.  A  simple  way  of  preparing  prunes  for 
this  purpose  is  to  pour  a  quart  of  boiling  water  over  an  ounce 
of  senna  leaves  and  allow  it  to  stand  for  about  two  hours.  A 
pound  of  well  washed  prunes  should  soak  over-night  in  this  infu- 
sion, which  has  been  strained,  and  the  combination  cooked  until 
tender.  They  may  be  sweetened  with  two  tablespoons  of  brown 
sugar,  and  the  flavor  improved  by  adding  a  stick  of  cinnamon  or 
slice  of  lemon  while  they  are  cooking.  Half  a  dozen  of  these 
prunes,  with  some  of  the  syrup,  may  be  taken  at  the  evening 


PRENATAL  CARE  121 

meal  to  start  with,  and  increased  or  decreased  in  number  as 
necessary. 

Clothes.  The  chief  purpose  of  clothes  under  all  conditions 
is  to  aid  in  keeping  the  body  warm,  thus  helping  to  preserve  an 
even  circulation  and  the  activity  of  the  sweat  glands.  As  has 
been  pointed  out,  this  is  of  especial  importance  during  preg- 
nancy. The  expectant  mother 's  clothes  should  be  not  only  suffi- 
ciently warm,  but  they  should  be  equally  warm  over  the  entire 
body.  They  should  be  light  and  porous,  and  fairly  loose,  so  as 
not  to  interfere  with  the  circulation  or  other  body  functions. 
There  must  be  no  pressure  on  chest  or  abdomen ;  no  tight  garters, 
belts,  collars  or  shoes. 

The  patient 's  clothes,  like  every  other  detail  in  her  care,  will 
have  to  be  adapted  to  her  environment  and  mode  of  living.  If 
her  house  is  Avell  and  evenly  heated  during  the  cold  months,  she 
may  quite  safely  dress  lightly  while  indoors;  if  it  is'  not,  she 
should  be  advised  to  wear  underwear  with  high  neck,  long  sleeves 
and  drawers,  both  indoors  and  out,  except  when  the  w^eather  is 
warm  enough  to  induce  free  perspiration.  At  all  times,  how- 
ever, the  warmth  of  her  clothing  must  be  adjusted  to  the  tern- 
perature  of  the  home,  the  climate  and  to  the  state  of  the  weather. 

Bearing  in  mind  the  importance  of  diversion  and  amuse- 
ments, it  becomes  apparent  that  in  addition  to  the  hj'gienic 
qualities  mentioned,  the  expectant  mother's  clothes  should  be 
as  pretty  and  becoming  as  is  consistent  with  her  circumstances. 
She  is  much  more  likely  to  go  about  and  mingle  with  her  friends 
if  she  is  fortified  with  the  consciousness  that  she  is  becomingly 
and  well  dressed.  Which,  of  course,  is  not  peculiar  to  pregnant 
women. 

The  expectant  mother's  clothes  should  be  so  made  that  their 
weight  will  hang  from  the  shoulders  instead  of  from  the  waist- 
band. 

And  that  brings  us  to  the  question  of  corsets,  one  of  the  most 
discussed  garments  in  her  wardrobe.  "Women  who  have  not 
been  accustomed  to  wearing  corsets  will  scarcely  feel  the  need 
of  adopting  them  during  pregnancy,  except  perhaps  during  the 
later  weeks  when  the  heavy,  pendulous  abdomen  needs  to  be 
supported  for  the  sake  of  comfort.    This  is  particularly  true  of 


rZ'Z  OBSTETRICAL  NURSING 

women  who  have  borne  children  and  whose  flaccid  abdominal 
walls  give  but  poor  support  to  the  uterus. 

Women  who  have  been  wearing  comfortable,  well-fitting  cor- 
sets probably  will  not  feel  the  need  of  making  a  change  until 
the  third  or  fourth  month.  By  this  time  the  uterus  has  pushed 
up  out  of  the  pelvis  into  the  abdomen  and  accordingly  the  corsets 
must  be  so  constructed  that  they  will  accommodate  themselves 
to  an  abdomen  that  is  steadily  increasing  in  size  and  also  chang- 
ing in  shape ;  will  provide  support  for  both  abdomen  and  breasts 
and  still  not  compress  nor  disguise  the  figure.  To  be  entirely 
satisfactory  in  their  adjustability,  the  maternity  corsets  must 
be  made  of  very  soft  material  and  have  elastic  inserts  and  side, 
as  well  as  front  or  back  lacings.  They  should  extend  well  down 
in  front  and  fit  snugly  over  the  hips.  The  upper  part  may  be 
fitted  with  adjustable  shoulder-straps  that  will  support  the 
breasts  and  help  to  suspend  some  of  the  abdominal  weight  from 
the  shoulders;  but  at  the  same  time  will  not  interfere  Avith  the 
development  of  the  breasts  nor  compress  the  nipples.  Many 
women  find  great  comfort  in  weaj'ing  a  short-waisted  maternity 
corset  and  a  brassiere. 

The  front-lace  corset  is  usually  found  to  be  the  most  satisfac- 
tory, for  the  patient  may  lace  it  from  below  upward  while  lying 
on  her  back.  This  enables  her  to  draw  it  in  snugly  about  the 
hips,  below  the  abdomen,  and  adjust  the  garment  to  the  abdomi- 
nal curve  so  as  to  really  support,  without  compressing  the  uterus. 
Other  excellent  corsets  lace  both  front  and  back  and  are  capable 
of  very  comfortable  adjustments.  If  the  nurse  clearly  under- 
stands the  purpose  of  a  maternity  corset,  she  will  be  able  to  ex- 
plain to  her  patient  why  the  same  style  as  she  ordinarly  wears, 
no  matter  how  large,  will  not  be  satisfactory  during  pregnancy, 
and  may  be  even  harmful. 

Even  a  properly  fitting  maternity  corset  may  become  uncom- 
fortable during  the  last  few  weeks  of  pregnancy,  and  have  to 
be  replaced  by  an  abdominal  supporter  of  linen  or  rubber.  And 
when  this  stage  is  reached,  even  the  woman  who  has  worn  no 
corsets  may  be  made  more  comfortable  by  adopting  such  a  sup- 
port, particularly  at  night.  There  are  many  admirable  binders 
on  the  market,  or  the  nurse  and  patient  may  fashion  some  such 


PRENATAL  CARE 


123 


>-■    O)    ^    4) 


2  ?  .t;  cj  CO  o  b. 

5f -;  c^i  *^  o  o  3 

>  C    >    3    H^  « 


124 


OBSTETRICAL  NURSING 


au  one  as  is  shown  in  Figs.  34,  35,  36  and  37.    Comfortable  and 
inexpensive  stocking  supporters,  which  meet  all  practical  re- 


FiG.   37. — Abdominal  binder  used  in  Figs.   34,  35   and  36,   showing   dart3 
at  top  of  front  to  fit  it  over  the  abdomen. 

qiiirements,  may  be  made  by  the  patient  from  tapes  or  strips  of 
muslin.     (Figs.  38  and  39.) 

The  expectant  mother's  shoes  also  merit  considerable  atten- 


FiGS.  38  and  39. — Front  and  back  view  of  home-made  stocking  sup- 
porters made  of  webbing  or  1-inch  strips  of  muslin  and  a  pair  of  child's 
side  garters.  The  straps  are  sewed  together  in  tlie  back,  but  pinned  in 
front  to  permit  adjustment  as  the  abdomen  enlarges.  (By  courtesy  of 
the  Maternity  Centre  Association,  New  York.) 


PRENATAL  CARE  125 

tion  and  thought.  Her  feet  are  larger  than  usual  because  they 
are  likely  to  be  somewhat  swollen  during  the  latter  part  of  preg- 
nancy, and  the  increased  weight  of  her  body  tends  to  spread 
them.  This  added  weight  also  increases  the  strain  put  upon 
the  arch  and  flat  foot  is  a  not  infrequent  result,  unless  the  arch 
is  well  supported.  Another  reason  for  the  need  of  proper  shoes 
is  that,  as  pregnancy  advances,  the  body's  centre  of  gravity 
changes.  The  pregnant  woman  becomes  unstable  on  her  feet  and 
needs  low,  broad,  firm  heels.  They  need  not  necessarily  be  flat 
at  first,  if  the  patient  has  been  accustomed  to  wearing  moderately 
high  ones,  for  the  sudden  lowering  of  the  heels  may  injure  her 
arches.  High  French  heels,  of  course,  should  be  avoided  because 
they  not  only  increase  the  difficulty  and  discomfort  of  walking 
but  cause  backache,  as  well,  by  forcing  a  posture  that  adds  to 
the  pressure  on  the  lower  part  of  the  abdomen.  They  also  in- 
crease the  risk  of  turning  the  ankles,  tripping  and  falling. 

The  patient's  shoes  should  be  an  inch  longer  than  those  she 
ordinarily  wears ;  they  should  have  broad  toes  and  fit  snugly  over 
the  instep,  in  spite  of  being  large.  If  her  shoes  are  not  comfort- 
able the  expectant  mother  Avill  tire  easily  and  tend  to  take  less 
exercise  than  she  should. 

Diet. — It  is  advisable  for  both  nurse  and  patient  to  under- 
stand, and  keep  clearly  in  mind,  the  purposes  w^hich  are  served 
by  the  food  intake  of  the  expectant  mother,  and  what  foods  and 
practices  will  defeat,  and  what  will  accomplish  these  purposes. 
Her  food  should  provide  nourishment,  as  under  ordinary  condi- 
tions; it  should  promote  the  functions  of  her  skin,  kidneys  and 
bowels,  because  of  the  wa.ste  from  her  own  and  her  baby's  body 
which  she  must  excrete ;  it  should  be  adequate  to  build  and  nour- 
ish the  baby's  body  without  drawing  materials  from  the  mother's 
own  tissues.  Moreover,  proper  food  during  pregnancy  is  an  es- 
sential factor  in  preparing  the  mother  to  nurse  her  baby,  which 
is  as  important  as  nourishing  the  fetus  in  utero. 

In  order  to  accomplish  these  various  ends  the  patient  must 
not  only  eat  suitable  food,  but  she  must  digest  and  assimilate  it. 
This  requires  that  she  sedulously  guard  against  overeating,  con- 
stipation  and   indigestion   of   any   kind.      Indigestion   may   be 


126  OBSTETRICAL  NURSING 

avoided  during  pregnancy  exactly  as  it  is  at  other  times,  by  eat- 
ing proper  food ;  by  cultivating  a  happy  frame  of  mind ;  by  ex- 
ercise, fresh  air,  adequate  rest  and  sleep. 

If  accustomed  to  a  fairly  simple,  well-balanced,  mixed  diet, 
the  average  expectant  mother  will  need  to  make  little  or  no 
change,  excepting  to  make  her  evening  meal  light  if  it  has  been 
a  hearty  one ;  for  she  uses  her  nutritive  material  with  surprising 
economy  and  does  not  have  to  * '  eat  for  two, "  as  is  so  commonly 
believed.  It  is  a  safe  general  principle  that  an  amount  and  kind 
of  food  that  keeps  the  expectant  mother,  herself,  in  a  state  of 
health  and  good  nutrition,  is  favorable  to  satisfactory  develop- 
ment of  the  fetus  until  the  latter  part  of  pregnancy. 

She  will  probably  be  able  to  understand  why  this  is  true  if 
it  is  explained  that  her  baby  gains  nine-tenths  of  his  weight  after 
the  fifth  month,  and  one-half  of  his  weight  during  the  last  eight 
weeks  of  pregnancy;  also  that  if  she  takes  too  much  food,  the 
excess  is  stored  up  in  both  her  own  and  the  baby's  tissues;  if 
too  little,  the  fetus  is  nourished  and  her  body  deprived. 

It  is  very  unwise  for  the  mother  to  diet  with  the  idea  of  keep- 
ing the  child  small,  and  thus  make  labor  easy,  unless  she  is  so 
ordered  by  her  physician.  In  general,  it  is  the  size  of  the  fetal 
skull  that  makes  labor  easy  or  difficult,  and  not  the  amount  of 
fat  distributed  over  the  child's  body.  And  if  the  patient  cuts 
down  the  minerals  in  her  diet  to  make  the  fetal  bones  soft,  and 
thus  increase  the  compressibility  of  the  skull,  the  fetus  will  ex- 
tract lime  from  her  bones  and  teeth,  so  that  the  only  effect  is 
upon  herself. 

The  expectant  mother's  meals  should  be  taken  with  clock-like 
regularity,  eaten  slowly  and  masticated  thoroughly.  Three  meals 
a  day  will  usually  suffice  during  at  least  the  first  half  of  preg- 
nancy. The  possible  need  for  slight  additional  food  after  that 
may  be  supplied  more  satisfactorily  by  lunches  of  milk,  cocoa 
or  broth  and  crackers  or  toast,  between  meals  and  upon  retiring, 
than  by  taking  larger  meals.  But  if  the  patient  has  a  tendency 
to  nausea,  early  in  pregnancy,  she  will  often  be  able  to  control 
it  by  taking  a  little  food  regularly  five  or  six  times  daily,  instead 
of  the  usual  three  meals. 


PRENATAL  CARE  127 

In  general  the  expectant  mother  should  eat  an  abundance  of 
fruit  and  vegetables,  taking  at  least  some  uncooked  fruit  and  a 
green  salad,  daily,  and  making  sure  that  her  food  contains  a 
good  deal  of  residue,  such  as  is  provided  by  fruit  and  coarse 
vegetables.  This  residue  increases  the  bulk  of  the  intestinal  con- 
tents, which  stimulates  peristaltic  action  and  thus  helps  to  over- 
come the  tendency  toward  constipation.  As  fat  is  less  easily 
digested,  and  more  likely  to  cause  nausea  during  pregnancy, 
than  carbohydrates,  it  is  better  for  the  patient  to  eat  no  more 
fat  than  usual,  but  to  supply  the  additional  energy  needed  after 
about  the  sixth  month,  by  taking  a  little  more  starch.  But  after 
all,  only  a  slight  increase  is  needed,  and  this  chiefly  during  the 
last  three  or  four  weeks. 

It  is  of  the  greatest  importance  that  every  pregnant  woman 
drink  an  abundance  of  fluid,  to  act  as  solvent  for  her  food  and 
waste  material,  and  stimulate  the  activity  of  her  kidneys,  skin 
and  bowels.  She  needs  about  three  quarts  daily,  and  most  of 
this  should  be  w^ater,  the  remainder  consisting  of  milk,  cocoa, 
soup,  and  other  liquids. 

Alcohol  should  not  be  taken  under  any  circumstances,  except 
upon  a  doctor's  order,  while  tea  and  coffee,  if  taken  at  all,  should 
be  used  with  moderation.  The  patient  should  be  advised  to 
avoid  fried  food,  pastry,  rich  desserts,  rich  salad-dressings  and 
any  other  food  which  would  ordinarily  disagree  with  her.  In 
fact  any  article  of  food  that  disagrees  w4th  her  in  a  non-preg- 
nant state  should  be  avoided  during  pregnancy,  no  matter  how 
valuable  it  may  be  as  nourishment  to  the  majority  of  people. 

On  the  other  hand,  it  sometimes  happens  that  an  article  of 
food  which  is  likely  to  disagree  with  other  people  will  be  easily 
digested  by  the  pregnant  woman,  and  if  it  adds  to  the  pleasure  of 
her  meals  should  not  be  taboo,  for  the  enjoyment  of  one's  meals 
promotes  digestion.  So-called  "cravings"  are  not  as  common 
in  fact  as  they  are  in  rumor,  but  the  expectant  mother  may  have 
a  capricious  appetite  and  display  strange  likes  and  dislikes  for 
certain  dishes,  possibly  because  of  her  tendency  to  be  nauseated. 

The  average  pregnant  woman  with  no  symptoms  of  complica- 
tions will  be  able  to  supply  her  needs,  and  at  the  same  time 


128  OBSTETRICAL  NURSING 

keep  within  the  bounds  of  safety  if  she  selects  her  diet  from  such 
groups  as  the  following: 

Animal  Foods. — Milk  and  eggs  are  the  most  satisfactory,  but  for 
the  sake  of  variety,  and  to  tempt  her  appetite,  she  will  usually  be 
allowed  to  have  fish,  the  various  kinds  of  shell  fish,  beef,  lamb,  chicken 
or  game  rather  sparingly,  preferably  only  once  a  day.  Pork,  veal, 
and  goose  should  be  avoided  as  a  rule,  and  particularly  by  women  with 
whom  they  ordinarily  disagree. 

Soups. — Thin  soups  and  broths  have  little  food  value,  but,  because 
of  their  appetizing  flavor  and  aroma,  are  an  aid  to  digestion,  and  fre- 
quently will  stimulate  a  flagging  appetite  and  prompt  the  patient  to 
eat  and  assimilate  more  than  she  would  without  them.  Cream  soups  and 
purees  obviously  have  a  high  food  value,  and,  like  thin  soups  and 
broths,  also  supply  a  definite  amount  of  fluid  which  the  patient  njust 
have. 

Vegetables. — The  group  of  vegetables  usually  designated  as  "leafy" 
are  of  even  greater  importance  to  the  expectant  mother  than  they  are 
to  the  average  person.  Of  these,  she  may  safely  eat  onions,  asparagus, 
celery,  string  beans,  spinach,  and  make  a  point  of  taking  a  green  salad, 
such  as  lettuce,  cress,  or  romaine,  at  least  once  daily.  Sweet  potatoes, 
white  potatoes,  rice,  peas,  Lima  beans,  tomatoes,  beets  and  carrots 
may  also  be  eaten  with  safety  as  a  rule,  but  cabbage,  caulifloAver,  corn, 
egg-plant,  Brussels  sprouts,  parsnips,  cucumbers,  and  radishes  should 
be  taken  with  great  caution  and  avoided  altogether  if  they  cause  flatu- 
lence or  any  kind  of  distress. 

Fresh  Fruits. — A  necessary  part  of  the  diet  is  fresh  fruit,  and 
among  those  fruits  which  are  both  beneficial  and  harmless  are  apples, 
peaches,  apricots,  pears,  oranges,  figs,  cherries,  pineapple,  grapes, 
plums,  strawberries,  raspberries,  blackberries,  and  grapefruit.  These 
are  more  likely  to  be  laxative  if  eaten  alone,  as  before  breakfast  and  at 
bedtime.  Cooked  fruits  are  also  valuable  articles  of  diet,  but  are  prob- 
ably less  laxative  than  raw  fruit.  Some  of  the  citrus  fruits,  oranges, 
grapefruit  and  lemons,  should  be  taken  daily  because  of  their  anti- 
scorbutic properties. 

Cereals. — For  their  nourishing  and  laxative  qualities,  cereals  are 
important,  and  their  food  value  is  increased  by  the  milk  and  cream 
which  are  usually  taken  with  them.  Cooked  cereals  should  invariably 
be  cooked  longer  than  the  usual  directions  suggest.  Bran,  eaten  alone, 
as  a  cereal  or  in  combination  with  other  grains,  is  an  excellent  laxative. 

Breads. — Graham,  cornmeal,  whole  wheat  and  bran  bread  are  all 
good.  In  general  the  expectant  mother  will  be  on  the  safe  side  if  she 
eats  sparingly,  if  at  all,  of  very  fresh  or  hot  breads  and  hot  cakes. 

Desserts. — Desserts  are  very  important  for  they  add  to  the  at- 
tractiveness of  most  people's  meals,  and  if  wisely  chosen  and  properly 


PRENATAL  CARE  129 

made,  may  supply  a  good  deal  of  easily  digested  nourishment.  They 
may  include,  in  addition  to  fresh  and  cooked  fruits  and  preserves,  ice- 
cream, a  wide  variety  of  custards,  creams  and  puddings  made  largely 
of  milk,  eggs,  and  some  ingredient  to  give  substance  and  firmness,  such 
as  gelatine,  cornstarch,  rice,  tapioca,  farina,  arrow-root  and  similar 
materials. 

Fresh  Air  and  Exercise.  If  the  nurse  has  become  aware  of 
the  value  of  promoting  aJl  of  the  normal  physiological  processes 
of  the  pregnant  woman,  she  already  realizes  how  important  are 
fresh  air  and  exercise  to  the  patient  and  her  expected  baby. 

The  average  individual  uses  every  minute  the  oxygen  con- 
tained in  four  bushels  of  air,  and  since  the  pregnant  woman 
takes  in  through  her  lungs  the  oxygen  for  both  herself  and  the 
baby,  she  must  have  an  adequate  quantity  of  constantly  chang- 
ing air  to  supply  at  least  this  amount.  She  should  spend  at  least 
two  hours  of  each  day  in  the  open  air.  If  the  weather  is  so 
stormy  or  severe  as  to  make  it  undesirable  for  her  to  go  out  from 
under  cover,  because  of  the  danger  of  getting  wet  or  chilled,  she 
may  wrap  up  well  and  take  her  airing  on  a  protected  porch  or 
in  a  room  with  all  of  the  windows  wide  open.  But  this  is  only 
a  part  of  it,  for  the  air  in  her  house,  or  rooms,  must  be  kept  fresh 
all  day  by  being  constantly  changed ;  this  requires  a  steady  in- 
pouring  of  fresh  air  and  outpouring  of  stale,  vitiated  air. 

A  very  good  way  to  accomplish  this  is  to  have  one  or  more 
windows  open  slightly,  top  and  bottom,  all  the  time.  But  there 
must  be  no  sudden  changes  of  temperature,  nor  drafts,  for  fear 
of  chilling  the  patient's  skin.  At  night  she  should  sleep  in  a 
room  with  the  windows  open,  taking  care  to  be  well  protected  by 
light,  warm  coverings. 

Each  detail  of  the  expectant  mother's  daily  routine  seems  to 
be  more  important  than  the  last.  And  so  when  we  come  to  the 
question  of  regular  outdoor  exercise  we  almost  think  that  what- 
ever else  may  be  neglected,  this  is  indispensable,  since  it  pro- 
motes digestion,  stimulates  the  functions  of  the  skin  and  lungs; 
steadies  the  nerves,  quiets  the  mind  and  promotes  sleep.  And 
more  than  that,  walking,  which  is  probably  the  most  satisfactory 
form  of  exercise,  also  strengthens  some  of  the  muscles  that  are 
used  during  labor.  But  exercise  is  downright  injurious  if  con- 
tinued to  the  point  of  fatigue,  no  matter  how  little  has  been 


130  OBSTETRICAL  NURSING 

taken.  Each  woman  must  be  a  law  unto  herself  in  this  matter, 
therefore,  and  must  be  impressed  with  the  importance  of  stop- 
ping before  she  is  tired.  She  should  start  by  walking  only  a 
short  distance,  increasing  gradually  until  she  is  able  to  walk 
possibly  as  much  as  an  hour  in  the  morning  and  an  hour  in  the 
afternoon,  if  she  can  do  so  without  fatigue. 

All  violent  exercises  and  sports  are  of  course  to  be  avoided, 
particularly  swimming,  horseback  riding,  and  tennis.  AVhile 
motoring  and  carriage  riding  are  pleasant  diversions,  they  can- 
not be  classed  as  exercise.  They  should  be  taken  only  in  com- 
fortable vehicles  and  over  smooth  roads,  so  that  there  will  be  no 
jarring  nor  jolting,  and  the  jDatient  should  not  do  the  driving 
herself. 

A  certain  amount  of  exercise,  in  the  shape  of  light  house- 
work, may  be  taken  indoors.  It  is  distinctly  beneficial,  if  not 
continued  to  the  point  of  fatigue,  both  because  of  the  exercise 
which  it  provides,  and  also  the  diversion  and  interest,  for  these 
promote  mental  and  physical  health.  But  this  indoor  exercise 
must  not  interfere  with,  nor  to  any  degree  replace,  the  daily 
exercise  out  of  doors ;  nor  must  it  include  heavy  work,  such  as 
washing,  sweeping,  heavy  lifting,  running  a  sewing  machine 
by  foot  nor  much  running  up  and  down  stairs.  However,  the 
amount  and  kind  of  work  which  a  woman  may  comfortably  and 
safely  do  are  so  related  to  what  she  has  been  accustomed  to,  that 
it  is  not  possible  to  offer  more  than  general  suggestions,  which 
will  help  in  the  planning  for  each  individual.  All  patients  will 
do  well  to  moderate  their  activities  at  the  time  when  they  would 
ordinarily  menstruate. 

There  are  patients  to  whom  massage  and  gymnastics  are  bene- 
ficial during  pregnancy,  when  for  some  reason  the  out-of-door 
activities  are  contra-indicated.  This  might  be  true  of  a  patient 
with  heart  trouble,  for  example,  or  one  who  is  being  kept  in  bed 
to  avert  an  abortion,  and  accordingly  is  a  matter  which  must  be 
entirely  in  the  doctor's  hands. 

Rest  and  Sleep.  When  we  studied  the  bony  structures  of 
the  female  body,  we  found  that  as  the  abdominal  tumor  of  preg- 
nancy increased  in  size  and  weight,  the  body's  centre  of  gravity 


PRENATAL  CARE  131 

changed  and  the  pregnant  woman  was  required  to  make  a  con- 
stant, though  unconscious  effort  to  stand  upright.  This  is  prob- 
ably one  reason  for  the  fatigue  which  expectant  mothers  so  often 
feel  without  apparent  cause,  and  for  the  fact  that  they  are  likely 
to  tire  rather  more  easily  than  usual. 

Accordingly,  the  patient  may  have  to  rest  frequently  during 
the  day,  in  order  to  avoid  the  ill  effects  of  fatigue.  She  should 
work  and  exercise  in  short  periods  rather  than  long,  always  lying 
down  when  tired,  and  for  an  hour  or  two  after  the  noon  meal. 
She  must  be  particularly  careful  not  to  be  over-active,  nor  to 
overexert  herself  at  the  time  when  menstruation  would  occur 
were  she  not  pregnant,  for  fear  of  bringing  on  an  abortion. 
This  precaution  is  particularly  important  during  the  first  four 
months,  the  period  when  abortions  occur  most  frequently. 

Since  eight  hours'  sleep  is  usually  considered  necessary  to 
keep  the  average  person  in  good  condition,  the  pregnant  woman 
cannot  expect  to  progress  satisfactorily  with  less.  In  fact,  it  is 
so  important  to  her  general  well-being  that  she  should  be  taught 
and  persuaded  to  do  everything  in  her  power  to  secure  it. 

Fresh  air  during  the  day  and  open  windows  at  night;  pru- 
dent eating;  a  comfortable  bed  furnished  with  warm  but  light 
bedding ;  warm  baths ;  a  hot  water  bag  to  the  feet  and  a  hot  drink 
upon  retiring  are  all  conducive  to  sleep. 

But  in  addition  to  these,  and  perhaps  of  even  more  import, 
are  cheerfulness  and  a  tranquil,  untroubled  state  of  mind.  It 
is  well  for  the  nurse  to  make  a  mental  note  of  that  intangible 
but  influential  fact,  for  she  can  usually  exert  a  great  deal  of 
influence  in  shaping  her  patient's  or  patients'  moods. 

Breasts. — Breast  feeding  is  the  most  urgent  single  need  of 
the  baby,  for  whose  coming  we  are  making  preparation,  and 
practically  every  mother,  excepting  those  with  definite  physical 
disability,  can  supply  this  need  of  her  baby 's,  if  she  gives  herself 
proper  care  both  before  and  after  its  birth.  It  is  true,  that  every- 
thing that  promotes  her  general  health  helps  to  prepare  her  to 
nurse  the  baby,  but  there  is  need  also  for  care  of  the  breasts  and 
nipples  themselves,  to  make  the  nursing  satisfactory,  and  to 
prevent  sore  nipples  and  possibly  even  breast  abscesses. 


132  OBSTETKICAL  NURSING 

Briefly,  this  local  care  consists  of  supporting  heavy  breasts, 
but  avoiding  pressure ;  bringing  out  flat  or  retracted  nipples  and 
toughening  the  skin  which  covers  the  nipples. 

After  they  become  heavy  and  uncomfortable  the  breasts  may 
be  supported  by  brassieres,  which  are  snug  below  the  breasts, 
loose  over  the  breasts  themselves  and  suspended  from  shoulder 
straps ;  or  by  some  such  binder  as  is  shown  in  Figs.  34,  35,  and  36, 
which  answers  the  same  purpose. 

If  the  patient's  nipples  are  flat  or  retracted,  she  should  be- 
gin about  the  fifth  month  to  make  them  more  prominent  in  order 
that  the  baby  may  grasp  them  easily.  There  are  several  ways 
of  accomplishing  this,  all  of  them  in  the  nature  of  massage,  but 
whatever  is  done  must  be  done  regularly  and  persistently.  One 
simple  and  effective  method  is  to  grasp  the  nipple  between  the 
thumb  and  forefinger,  draw  it  out,  hold  it  for  a  moment,  then 
release  it  and  allow  it  to  retract.  This  should  be  done  over  and 
over,  two  or  three  times  daily.  Or  the  unstoppered  opening  of  a 
warm  bottle  may  be  placed  over  a  flat  nipple  and  held  in  place 
until  the  nipple  is  drawn  up  into  the  neck  of  the  bottle  as  it 
cools  and  forms  a  vacuum. 

The  toughening  of  the  nipples  should  be  begun  eight  weeks 
before  the  baby  is  expected.  There  are  two  general  methods 
which  seem  to  give  about  equally  satisfactory  results;  one  is  to 
harden  the  skin  with  astringents  and  the  other  is  to  soften  it  with 
ointments.  In  either  case,  the  nipples  should  first  be  scrubbed 
gently  with  a  soft  brush  or  cloth,  warm  water  and  soap,  for 
about  five  minutes  night  and  morning.  They  may  then  be  rubbed 
with  lanoline,  cocoa-butter  or  vaseline  and  covered  with  a  piece 
of  clean  soft  cloth  or  gauze,  to  protect  the  clothing;  or  they 
may  be  bathed  with  a  wash  consisting  of  equal  parts  of  a  satu- 
rated solution  of  boracic  acid  and  95%  grain  alcohol.  Tannin, 
benzoin  and  a  great  variety  of  astringents  are  also  used,  and 
with  satisfactory  results.  But  the  essential  is  to  decide  upon 
some  method  of  preparation,  of  proved  value,  and  then  persuade 
the  patient  to  employ  it  with  faithful  regularity. 

Care  of  the  Teeth.  It  is  important  that  the  pregnant 
woman  give  her  teeth  excellent  care,  for  in  addition  to  the  condi- 
tions with  which  we  all  have  to  cope,  she  must  combat  the  effect 


PRENATAL  CARE  133 

of  her  tendency  to  have  an  acid  stomach.  And  her  teeth  are 
prone  to  decay  and  crumble,  since  the  fetus  extracts  lime  salts 
from  her  bones  and  teeth,  unless  she  is  careful  to  take  in  through 
her  food  a  supply  which  is  adequate  to  meet  the  fetal  needs.  It 
is  therefore  advisable  for  her  to  place  herself  under  the  care  of  a 
dentist,  as  soon  as  she  knows  of  her  pregnancy,  and  have  any 
necessary  work  done  at  that  time,  as  delay  may  be  serious. 

Some  physicians  think  it  advisable  to  have  an  X-ray  examin- 
ation of  the  teeth  made  as  a  routine,  in  order  to  discover  any 
existing  pockets  of  pus  at  the  apices  of  devitalized  teeth.  They 
feel,  that  because  of  the  somewhat  unstable  condition  of  the  preg- 
nant organism,  these  localized  infections  are  more  of  a  menace 
to  the  expectant  mother  than  to  the  ordinary  individual,  and  that 
in  some  cases  they  should  be  drained. 

As  to  daily  care  of  the  teeth,  the  patient  should  use  dental 
floss  and  brush  her  teeth  after  each  meal,  and  use  an  alkaline 
mouth  wash  several  times  daily,  particularly  after  vomiting  and 
before  retiring.  Much  damage  may  be  done  by  the  acid  secre- 
tions in  the  mouth  if  they  are  allowed  to  bathe  the  teeth  through 
the  long  night  stretches.  Common  cooking-soda,  lime-water  or 
milk  of  magnesia  make  excellent  mouth  washes. 

Traveling.  In  this  day,  when  people  travel  so  much  and  so 
easily,  it  is  common  to  hear  discussions  as  to  its  advisability  for 
the  prospective  mother.  Like  many  other  details  of  prenatal 
care,  this  point  cannot  be  settled  once  for  all  women,  nor  for  all 
stages  of  pregnancy.  Each  patient's  general  condition  must  be 
considered ;  her  tendency  to  nausea ;  the  length  of  the  journey 
and  the  ease  with  which  it  may  be  made,  and  whether  or  not 
she  has  ever  had,  or  been  threatened  with  an  abortion.  In  gen- 
eral, traveling  is  less  hazardous  for  the  expectant  mother  to-day 
than  it  was  formerly,  to  just  the  extent  that  it  causes  less  strain, 
discomfort  and  fatigue.  But  as  a  rule  it  is  considered  wise  for 
her  to  avoid  traveling  during  the  first  sixteen  and  the  last  four 
wrecks  of  pregnancy,  and  at  the  times  when  menstruation  would 
ordinarily  occur^  Obviously,  then,  in  the  interests  of  prevention, 
a  journey  should  not  be  undertaken  at  any  time  without  a  physi- 
cian's approval. 

The  marital  relation  is  usually  considered  inadvisable  in  all 


134  OBSTETRICAL  NURSINU 

cases  after  the  eighth  month  of  pregnancy,  and  among  women 
who  have  had  abortions  or  miscarriages  it  is  best  omitted 
throughout  the  entire  period  of  gestation.  This  is  particularly 
true  of  elderly  primiparae, 

COMMON  DISCOMFORTS  DURING  PREGNANCY 

There  are  many  minor  disturbances  which  overtake  the  preg- 
nant woman,  and  though  not  serious  in  themselves,  her  com- 
fort is  greatly  increased  by  having  them  relieved,  and  this  pro- 
motes her  general  welfare.  The  relief  of  these  discomforts,  when 
they  are  slight  or  only  temporary,  sometimes  resolves  itself  into 
little  more  than  a  question  of  nursing.  When  long  continued  or 
severe,  however,  they  constitute  complications  which  the  doctor 
treats  accordingly. 

Nausea  and  vomiting  are  probably  the  commonest  disturb- 
ances of  pregnancy  and  vary  from  the  slightest  feeling  of  nausea 
when  the  patient  first  raises  her  head  in  the  morning,  to  persist- 
ent and  frequent  vomiting  which  then  assumes  grave  proportions 
and  is  termed  "pernicious  vomiting."  Although  it  is  possible 
that  even  the  slightest  nausea  is  due  to  a  mild  toxemia,  there 
can  be  no  doubt  that  in  many  instances  the  patient's  mental  at- 
titude is  an  important  factor. 

Dr.  Slemons  makes  the  interesting  observation,  that  women 
who  are  unaware  of  their  pregnancy  for  several  months  are  sel- 
dom troubled  with  nausea,  while  those  who  erroneously  believe 
themselves  to  be  pregnant  will  suffer  from  this  well-known  symp- 
tom of  pregnancy,  until  convinced  of  their  mistake.  The  nausea 
then  subsides. 

As  there  is  a  marked  tendency  toward  nausea  during  early 
pregnancy,  it  may  be  brought  on  by  slight  causes  which  would 
not  produce  it  under  ordinary  conditions.  Anxiety,  grief, 
fright,  shock,  incessant  worrying,  fits  of  rage,  introspection, 
brooding,  or  any  great  emotional  stress  may  cause  nausea  when 
the  diet  is  entirely  satisfactory.  But  indiscretions  in  diet,  rapid 
or  over-eating  also  may  cause  nausea  and  vomiting  in  the  ex- 
pectant mother. 

We  seem  to  get  back  to  the  principles  of  personal  hygiene  a? 


PRENATAL  CARE  135 

preventives  of  nausea  during  ])reg:naney,  for  simple,  light  food, 
taken  in  small  (jiiantities  five  or  six  times  daily,  eaten  slowly  and 
masticated  thoroughly;  the  cultivation  of  a  happy  frame  of 
mind;  exercise  and  fresh  air  all  tend  to  avert  this  very  uncom- 
fortable condition.  Its  prevention  is  of  great  importance,  as  the 
habit  of  vomiting  is  easily  acquired  but  broken  with  difficulty. 
The  common  causes  of  nausea,  and  their  prevention,  should  there- 
fore be  explained  to  the  average  patient,  for  she  will  then  be 
able  to  help  herself  in  warding  it  off. 

Should  "morning  sickness"  occur,  however,  it  may  be  re- 
lieved in  many  cases,  by  eating  two  or  three  hard,  unsweetened 
crackers  or  pieces  of  toast,  with  nothing  to  drink,  immediately 
upon  awakening  and  then  lying  still  afterwards  for  half  or  three 
quarters  of  an  hour.  The  sufferer  should  then  dress  slowly,  sit- 
ting down  as  much  as  possible  while  doing  so,  and  eat  her  regu- 
lar breakfast.  Lying  flat,  without  a  pillow,  and  keeping  veiy 
quiet  for  a  little  while  after  meals,  or  whenever  feeling  the  slight- 
est premonitory  symptom,  will  frequently  prevent,  and  also  re- 
lieve nausea,  and  sometimes  comfort  is  derived  from  the  use  of 
either  hot  or  cold  applications  to  the  abdomen.  Some  patients  are 
relieved  by  having  hot  coffee  or  even  a  full  breakfast  before 
arising. 

Heartburn,  so  called,  which  is  experienced  by  many  pregnant 
women,  has  nothing  to  .do  with  the  heart.  It  is  caused  solely 
by  an  excess  of  hydrochloric  acid  in  the  stomach,  and  is  usually 
described  as  a  burning  sensation  first  in  the  stomach,  then  ris- 
ing into  the  throat.  It  may  be  prevented,  as  a  rule,  by  taking 
a  tablespoonful  of  olive  oil,  or  a  cupful  of  cream  or  rich  milk, 
fifteen  or  twenty  minutes  before  meals,  and  avoiding  fat  and 
fried  food  at  the  meals  immediately  following. 

This  apparent  inconsistency  in  treatment  is  due  to  the  facts 
that  fat  taken  into  the  empty  stomach  tends  to  inhibit  the  secre- 
tion of  acid,  while  fat  and  fatty  foods  taken  witJi  meals  tend 
to  prolong  their  stay  in  the  stomach  and  this  in  turn  stimulates 
the  secretion  of  hydrochloric  acid,  the  thing  to  be  avoided. 

A  patient  with  a  tendency  to  heartburn  will  be  wise,  there- 
fore, if  she  generally  eliminates  oils,  fats  and  fattv  foods  from 


136  OBSTETRICAL  NURSING 

her  meals,  and  definitely  avoids  them  when  the  burning  occurs. 
Since  the  painful,  burning  sensation  is  directly  due  to  an  excess 
of  acid  in  the  stomach,  the  obvious  step  toward  relief  is  to  take 
an  alkali  at  once.  A  tablespoonful  of  lime-water  is  often  satis- 
factory ;  a  teaspoonful  of  sodium  bicarbonate  in  water ;  a  small 
piece  of  magnesium  carbonate  may  be  nibbled  by  itself,  or  any 
alkaline  water  that  the  patient  fancies  may  be  taken. 

Distress.  There  is  another  form  of  discomfort,  often  vague 
and  ill-defined,  commonly  called  "distress"  and  occurring  after 
eating.  It  may  be  neither  heartburn  nor  pain,  but  resemble 
both  and  make  the  patient  very  miserable.  It  is  usually  seen  in 
women  who  eat  rapidly,  do  not  chew  their  food  thoroughly  or 
eat  more  at  one  time  than  the  stomach  can  hold  comfortably. 
The  prevention,  naturally,  lies  in  taking  small  amounts  of  food 
slowly  and  masticating  thoroughly. 

Flatulence  may  or  may  not  be  associated  with  heartburn, 
but  it  is  fairly  common  and  rather  uncomfortable.  It  is  usually 
due  to  bacterial  action  in  the  intestines,  which  results  in  the 
formation  of  gas.  As  has  been  previously  explained,  the  pres- 
sure of  the  enlarged  uterus  upon  the  intestines  and  absence  of 
pressure  by  the  abdominal  muscles,  retards  normal  peristalsis, 
with  the  result  that  gas  sometimes  accumulates  to  a  very  uncom- 
fortable extent.  It  is  clear,  therefore,  that  a  daily  bowel  move- 
ment is  of  prime  importance  in  preventing  and  relieving  flatu- 
lence, and  also  that  foods  which  form  gas  should  be  carefully 
excluded  from  the  diet.  The  chief  offenders  are  parsnips,  beans, 
corn,  fried  foods,  sweets  of  all  kinds,  pastry  and  very  sweet  des- 
serts. Various  intestinal  disinfectants  are  employed,  as  in 
non-pregnant  states,  and  also  yeast  cakes,  cultures  of  Bulgarian 
bacilli  and  artificially  fermented  milk  containing  bacteria  that 
are  antagonistic  to  the  gas-producing  forms. 

In  the  opinion  of  some  doctors,  flatulence  is  sometimes  an 
early  symptom  of  toxemia. 

Diarrhea.  Although  diarrhea  is  not  one  of  the  commonest 
disturbances  of  pregnancy,  neither  is  it  infrequent,  and  must  be 
borne  in  mind  in  connection  with  digestive  troubles.  Of  course, 
a  pregnant  woman  may  have  an  attack  of  diarrhea  from  the 
same  causes  that  produce  it  in  any  one  else,  and  its  relief  would 


PRENATAL  CARP]  137 

be  obtained  by  the  usual  methods,  chiefly  the  correction  of  dietetic 
errors.  But  on  the  other  hand,  it  may  be  due  entirely  to  the 
uterine  pressure  on  irritable  intestines.  Like  flatulence,  it  is 
regarded  by  some  doctors  as  a  possible  symptom  of  toxemia.        " 

Pressure  Symptoms.  Under  the  general  heading  of  pressure 
symptoms  are  several  forms  of  discomfort  resulting  from  pres- 
sure of  the  enlarged  uterus  on  the  veins  returning  from  the  lower 
part  of  the  body,  thus  interfering  with  the  flow  of  blood  back  to 
the  heart.  As  both  the  cause  and  relief  of  these  symptoms  are 
associated  with  the  force  of  gravity,  the  nurse  will  usually  know 
what  to  do  in  mild  cases  without  further  explanation.  In  general 
the  heavy  abdomen  should  be  supported  by  a  binder  or  properly 
fitting  corset,  the  patient  should  keep  off  her  feet  as  much  as  pos- 
sible and  elevate  the  swollen  part. 

The  commonest  pressure  symptoms  are  swollen  feet,  varicose 
veins,  hemorrhoids,  cramps  in  the  legs  and  shortness  of  breath, 
and  though  they  may  appear  at  any  time  during  the  last  half, 
of  pregnancy,  they  grow  progressively  worse  as  pregnancy  ad- 
vances. 

Swelling  of  the  feet  is  very  common,  .and  when  very  slight 
may  not  be  serious  nor  particularly  uncomfortable.  The  edema 
may  be  confined  to  the  hack  of  the  ankle,  which  grows  white  and 
shining,  or  it  may  extend  all  the  way  up  the  legs  to  the  thighs 
and  include  the  vulva.  Sitting  down,  with  the  feet  resting  on  a 
chair,  or  lying  down  with  the  feet  elevated  on  a  pillow  will 
naturally  give  a  certain  amount  of  relief.  If  the  swelling  and 
discomfort  are  extreme  the  patient  may  have  to  go  to  bed  until 
they  subside,  but  very  often  she  will  secure  adequate  relief  by 
elevating  her  feet  for  even  a  little  while,  several  times  a  day. 
But  while  employing  these  harmless,  and  clearly  indicated  meas- 
ures, to  make  her  patient  comfortable,  the  nurse  must  be  keenly 
alive  to  the  fact  that  while  edema  of  the  feet,  legs  and  vulva 
may  be  of  solely  mechanical  origin,  they  are  also  symptoms  of 
toxemia,  about  the  most  dreaded  complication  of  pregnancy. 
And  as  recognition  of  the  earliest  signs  of  toxemia  is  among  the 
triumphs  of  prenatal  nursing,  even  the  slightest  swelling  must 
be  reported  to  the  doctor  and  immediate  steps  taken  to  have  the 
urine  measured  and  examined. 


138 


OBSTETRICAL  NURSING 


Varicose  veins  are  not  peculiar  to  pregnancy,  but  are  among 
the  pressure  symptoms  which  frequently  accompany  this  condi- 
tion during  the  later  months,  particularly  among  women  who 
have  borne  children.  The  superficial  veins  in  the  legs  will  often 
be  equal  to  the  tension  put  upon  them  the  first  time,  but  will 
give  way  as  the  strain  is  repeated  during  subsequent  pregnancies. 
The  distension  of  the  veins  is  not  serious  as  a  rule,  but  may  be 
very  uncomfortable;  this,  coupled  with  the  unsightly  appear- 
ance, sometimes  has  a  bad  mental  effect.    Varicose  veins  may  oc- 


FiG.  40. — Eight  angled  position,  to  relieve  edema  or  varicose  veins  of  feet 
and  legs.      (By  courtesy   of   The   Maternity   Centre  Association.) 

cur  in  the  vulva,  but  they  are  usually  confined  to  the  legs,  and 
both  legs  are  about  equally  affected.  But  as  the  position  of  the 
child  in  utero  may  exert  greater  pressure  on  the  right  than  on 
the  left  side,  the  veins  on  that  side  may  be  more  distended;  or 
the  right  side  alone  may  be  affected. 

Relief  is  obtained  by  keeping  off  the  feet,  and  particularly  by 
elevating  them  and  also  by  the  use  of  elastic  bandages.  When 
a  woman  finds  it  difficult  or  nearly  impossible  to  sit  or  lie  down 
for  any  length  of  time,  she  may  accomplish  a  great  deal  in  a  few 
moments  by  lying  flat  on  the  bed  with  her  legs  extended  straight 


PRENATAL  CARE  139 

into  the  air,  at  right  angles  to  her  body,  resting  against  the  wall 
or  head  board,  as  shown  in  Fig.  40.  This  vight-angled  position 
for  five  minutes,  three  or  four  times  a  day  will  accomplish  won- 
ders in  reducing  varicose  veins. 

In  addition  to  posture,  a  spiral  elastic  bandage  will  give  re- 
lief and  help  to  ])revent  the  veins  from  growing  larger,  if  ap- 
plied freshly  after  each  time  that  the  leg  is  elevated.  The  most 
satisfactory  bandages,  from  the  standpoint  of  expense,  comfort 
and  cleanliness,  are  of  stockinette  or  of  flannel  cut  on  the  bias, 
measuring  three  or  four  inches  wide  and  eight  or  nine  yards 
long.  If  made  of  flannel,  the  selvedges  should  be  whipped  to- 
gether smoothly  so  that  there  is  neither  ridge  nor  pucker  at  the 
seam.     The  bandage  should  be  applied  spirally  with  firm,  even 


Pig.  41. — Elevated  Sims '  position  to  relieve  varicose  veins  of  the  vulva. 
(By  courtesy  of  The  Maternity  Centre  Association.) 

pressure,  starting  with  a  few  turns  over  the  foot  to  secure  it,  and 
leaving  the  heel  uncovered,  carried  up  the  leg  to  a  point  above 
the  highest  swollen  vessels.    As  a  rule,  it  may  be  left  off  at  night. 

There  are  satisfactory  elastic  stockings  on  the  market,  but 
they  are  expensive,  often  cannot  be  washed  and  seem  to  offer  no 
advantage  over  the  bandages. 

Engorged  veins  in  the  vulva  may  be  relieved  by  lying  flat 
and  elevating  the  hips,  or  by  adopting  the  elevated  Sims'  posi- 
tion for  a  few  moments,  several  times  a  day.     (Fig.  41). 

Hemorrhoids  are  virtually  varicose  veins  which  protrude 
from  the  rectum,  but,  unlike  those  in  the  legs,  are  extremely 
painful.  As  it  is  the  straining  incident  to  constipation  that 
causes  these  engorged  veins  to  prolapse,  this  condition  constitutes 


140  OBSTETRICAL  NURSING 

one  more  reason  for  preventing  constipation.  A  pregnant  wo- 
man whose  bowels  move  freely  every  day  rarely  has  hemorrhoids. 

Should  hemorrhoids  appear,  the  first  step  is  to  have  them 
gently  pushed  back  into  the  rectum.  The  patient  can  usually  do 
this  for  herself,  quite  satisfactorily,  after  lubricating  her  fingers 
with  vaseline  or  cold  cream.  Lying  down,  with  the  hips  elevated 
on  a  pillow;  the  application  of  an  ice  bag,  cold  cloths  or  witch- 
hazel  compresses  to  the  anus  will  almost  always  give  relief. 
When  the  condition  is  severe,  the  physician  may  prescribe  medi- 
cated ointments,  lotions  or  suppositories,  but  operation  is  seldom 
resorted  to  during  pregnancy,  for  fear  of  bringing  on  labor 
prematurely.  Sometimes  the  hemorrhoids  are  worse  during  the 
first  few  days  after  labor,  but  as  a  rule  they  disappear  with 
the  removal  of  the  cause,  which  in  this  case  is  pressure  made  by 
the  enlarged  uterus. 

Cramps  in  the  legs,  numbness  or  tingling  may  be  caused  by 
the  pressure  of  the  large,  heavy  uterus  upon  nerve  trunks  sup- 
plying the  lower  extremities.  The  recumbent  position ;  applying 
heat  and  rubbing  the  painful  areas  will  often  give  comfort. 

Shortness  of  breath  is  sometimes  very  troublesome  toward 
the  end  of  pregnancy,  and,  as  may  be  easily  seen,  is  due  to  the 
upward,  and  not  downward  pressure  of  the  uterus.  For  this 
reason  it  is  aggravated  by  the  patient 's  lying  down  and  relieved 
by  her  sitting  up  or  being  well  propped  up  on  pillows,  or  a  back 
rest. 

Vaginal  discharge.  The  normal  vaginal  discharge  is  greatly 
increased  during  the  latter  months  of  pregnancy,  as  was  pointed 
out  in  Chapter  V,  so  that  ordinarily  the  moderately  profuse 
yellowish  or  white  discharge  at  this  time  has  no  particular  sig- 
nificance. Its  existence  should  be  noted,  however,  and  brought 
to  the  doctor's  attention,  for  a  very  profuse  discharge  is  likely 
to  be  regarded  as  a  possible  evidence  of  gonorrhea.  For  this 
reason  a  smear  is  usually  made,  when  the  discharge  is  excessive, 
to  establish  or  eliminate  this  diagnosis ;  if  it  is  positive,  it  indi- 
cates the  necessity  for  treatment  to  safeguard  both  mother  and 
baby. 

As  the  normal  vaginal  discharge  has  antiseptic  properties,  it 
should  not  be  removed  by  douches,  which  many  patients  are 


PRENATAL  CARE  141 

eager  to  take ;  but  if  it  is  irritating  and  causes  itching  or  burn- 
ing the  patient  may  be  made  entirely  comfortable  by  avoiding 
the  use  of  soaj)  and  1)y  l)athinj>'  tlie  vulva  mtli  a  solution  of 
sodium  bicarbonate  or  with  olive  oil. 

Itching  of  the  skin  is  a  fairly  common  discomfort,  and  is 
possibly  ii  result  of  irritating  material  being  excreted  by  the 
skin  glands  and  deposited  upon  the  surface  of  the  body.  The 
local  irritation  usuall.y  may  be  alla3'ed,  if  not  very  severe,  by 
bathing  the  uncomfortable  areas  with  a  solution  of  sodium  bicar- 
bonate, or  a  lotion  consisting  of  a  pint  of  lime-water,  half  an 
ounce  of  glycerine  and  thirty  drops  of  carbolic  acid.  It  is  a 
good  plan,  also,  for  the  patient  to  increase  the  amount  of  fluids 
which  she  is  taking,  in  order  to  promote  the  activity  of  the  skin, 
kidneys  and  bowels,  and  thus  dilute  the  material  that  may  be 
responsible  for  the  itching  and  increase  its  elimination  through 
all  channels.  In  other  words  the  itching  may  be  due  to  a  mild 
toxemia. 

Some  women  complain  of  discomfort  caused  by  the  stretching 
of  the  skin  over  the  enlarged  a])domen,  which  becomes  so  tense 
it  feels  as  though  it  might  tear  apart.  There  is  a  very  old  and 
widely  current  belief  that  this  sensation  may  be  relieved  by 
nibbing  the  abdomen  with  some  kind  of  an  oil  or  ointment.  And, 
moreover,  that  such  oiling  will  not  only  increase  the  elasticity  of 
the  superficial  layers  of  the  skin,  but  the  deeper  layers  as  well, 
and  that  by  this  means  striae  may  be  prevented.  There  seems 
to  be  little  foundation  for  the  fear  that  the  skin  will  tear,  or 
belief  in  the  efficacy  of  the  oiling,  but  if  a  woman  fancies  that  she 
is  safer  and  more  comfortable  after  oiling  her  abdomen,  there 
is  certainly  no  reason  why  she  should  not  do  so. 

EARLY  SIGNS  OF  COMPLICATIONS  OF  PREGNANCY 

It  is  evident  that  by  teaching  the  principles  of  personal  hy- 
giene to  the  expectant  mother  so  convincingly  that  she  will  adopt 
them,  and  sometimes,  by  employing  simple  nursing  procedures 
to  relieve  the  various  discomforts  of  pregnancy,  much  will  be 
accomplished  toward  promoting  the  welfare  of  both  the  patient 


142  OBSTETRICAL  NURSING 

and  the  expected  baby.  But  this  is  not  enough.  The  nurse  must 
also  be  on  the  alert  to  detect  and  report  the  early  symptoms  of 
complications,  for  there  may  be  times  Avhen  she  will  be  the  first 
one  to  see  the  patient  after  a  symptom  has  developed. 

The  principal  complications  of  pregnancy  which  are  amen- 
able to  preventive  or  early  treatment  are  the  toxemias,  jDrema- 
ture  terminations  of  pregnancy  and  hemorrhage. 

The  causes  of  these  conditions  and  the  details  of  treatment 
and  nursing  care  are  so  inextricably  associated  with  each  other 
that  they  are  discussed  together  and  at  some  length  in  another 
chapter.  But  their  most  conspicuous,  early  signs  are  briefly 
noted  here,  since  watching  for  them  constitutes  a  part  of  routine 
prenatal  care. 

The  toxemias  are  apparently  caused  by  disturbed  metab- 
olism and  impaired  or  inadequate  excretory  processes.  Their 
prevention  is  to  be  accomplished  largely  by  observing  the  prin- 
ciples of  personal  hygiene  previously  described,  and  in  quickly 
treating  early  symptoms.  One  of  the  commonest  of  these  symp- 
toms is  headache,  sometimes  persistent  and  very  severe.  Others 
are  disturbed  vision,  dizziness  and  more  persistent  or  severe 
vomiting  than  could  reasonably  be  called  "morning  sickness"; 
puffiness  under  the  eyes,  or  elsewhere  about  the  face,  or  of  the 
hands;  anything  more  than  very  slight  swelling  of  the  feet  and 
ankles ;  high  or  increasing  blood  pressure ;  mental  depression ; 
albumen  in  the  urine,  amounting  to  more  than  a  trace,  and 
epigastric  pain,  are  all  possible  symptoms  of  toxemia.  A  patient 
in  whom  even  one  of  these  symptoms  appears  is  iLsually  placed 
under  close  observation ;  frequently  put  to  bed  and  her  diet 
restricted  to  milk,  or  even  water,  until  the  symptoms  subside. 

The  common  symptoms  of  premature  termination  of  preg- 
nancy, (an  abortion,  miscarriage  or  i)remature  labor)  are 
bleeding,  Avith  or  without  pain  in  the  small  of  the  back,  followed 
by  cramp-like  pains  in  tlio  abdomen.  Bleeding  or  a  bloody  dis- 
charge, therefore,  irrespective  of  pain  should  be  regarded  as  a 
symptom  of  pending  labor  and  the  patient  should  be  put  to  bed 
promptly,  and  kept  quiet.  Preventive  treatment,  after  preg- 
nancy has  begun,  consists  largely  of  rest,  particularly  at  the  time 
when  menstruation  Avould  ordinarily  occur;  avoidance  of  physi- 


PRENATAL  CARE  143 

ca\  shocks  and  of  overwork  during  the  later  weeks.  Prolonged 
failure  on  the  part  of  the  patient  to  feel  fetal  movements  or 
of  the  nurse  or  doctor  to  hear  the  fetal  heartbeat  after  they 
have  once  been  manifest  usually  indicates  the  death  of  the  child 
and  precedes  its  expulsion. 

Bleeding,  or  a  sudden  increase  in  the  size  of  the  uterus  with 
a  rapid  pulse  or  general  symptoms  of  shock,  may  be  the  symp- 
toms of  hemorrhage  caused  by  placenta  pnevia  or  premature 
separation  of  a  normally  implanted  placenta;  upon  the  appear- 
ance of  any  one  of  these  signs  the  patient  should  be  put  to  bed 
and  kept  absolutely  quiet. 

To  sum  up,  we  find  that  the  following  symptoms  may  be  fore- 
runners of  serious  complications,  and  therefore  should  be  watched 
for  and  reported  to  the  doctor  immediately  upon  their  discovery : 

1.  Persistent  or  severe  vomiting. 

2.  Persistent  or  severe  headache. 

3.  Dizziness. 

4.  Disturbed  vision  or  the  appearance  of  black  spots  before  the 
eyes. 

5.  Pi;ffiness  under  the  eyes,  or  elsewhere  about  the  face. 

6.  Swelling  of  the  feet,  ankles  or  hands. 

7.  Sharp  pains,  particularly  in  the  epigastric  region. 

8.  Prolonged  failure  to  feel  fetal  movements  after  they  have  once 
been  felt. 

9.  Cessation  of  the  fetal  heartbeat,  or  a  marked  change  in  its 
rate  or  rhythm. 

10.  Bleeding,  or  a  bloody  discharge. 

11.  Pain  in  the  lumbar  region,  folloAved  by  cramp-like  pains  in  the 
abdomen,  before  the  expected  date  of  confinement. 

12.  Albumen  in  the  urine. 

13.  High,  or  increasing  blood  pressure. 

14.  Unwarranted  mental  depression,  anxiety  or  apprehension. 

These  are  generally  accepted  as  the  cardinal  danger  signs  of 
pregnancy,  any  one  of  which,  alone  or  in  combination  with  one 
or  more  of  the  others,  is  of  significance  and  should  be  reported 
to  the  doctor  at  once. 

When  all  is  said  and  done,  our  wish  for  the  expectant  mother 
is  for  little  more  than  that  she  shall  live  a  normal,  wholesome 
life;  that  she  shall  be  willing,  and  also  be  able  to  weave  into  her 
every  day  life  the  principles  of  personal  hygiene  which  every  one 


144  OBSTETRICAL  NURSING 

should  adopt ;  that  she  shall  be  carefully  watched  for  complica- 
tions throughout  the  entire  period  of  pregnancy,  and  that  these 
complications  shall  be  speedily  treated. 

Adoption  of  personal  hygiene,  then,  and  prevention  of  com- 
plications by  their  early  detection  and  treatment — these  we  want 
for  every  woman  who  is  looking  forward  to  motherhood. 

For  lack  of  these  things  there  are  sick  and  blind  and  maimed 
babies  and  invalid  women ;  there  are  lonely,  motherless  children 
and  bereaved  mothers  in  every  corner  of  our  land. 


CHAPTER  VII 
MENTAL  HYGIENE  OF  THE  EXPECTANT  MOTHER 

It  is  only  once  in  a  long  time  that  the  obstetrical  nurse  has  a 
patient  who  is  suffering  from  such  a  marked  mental  disturbance 
that  her  condition  is  diagnosed  and  treated  as  a  psychosis.  But 
more  often  than  not  she  has  a  patient  who  is  secretly  suffering  a 
good  deal  of  mental  stress  and  pain,  which  is  not  recognized  and 
not  treated. 

In  fact,  by  virtue  of  the  deep  significance  of  the  states  of 
pregnancy  and  motherhood,  and  the  long  period  of  time  through 
which  they  continue,  it  is  scarcely  possible  for  them  not  to  pro- 
duce a  mental  effect  of  some  sort  upon  the  average  woman. 
Sometimes  this  effect  is  a  very  happy  one ;  but  all  too  often  it  is 
quite  the  reverse.  It  is  safe  to  say  that  the  majority  of  maternity 
patients  are  passing  through  deep  waters,  and  the  nurse's  use- 
fulness to  these  charges  will  be  greatly  broadened  if  she  has  at 
least  some  understanding  of  the  cause  and  character  of  these  men- 
tal sufferings. 

In  the  ordinary  course  of  events,  from  birth  to  death,  we  all 
of  us  are  being  called  upon  continuously  to  adjust  ourselves  to 
all  sorts  of  experiences,  situations  and  emotional  strains  peculiar 
first  to  early  childhood,  then  the  school  epoch,  the  period  of 
emancipation  from  home  and  finally  to  the  life  work.  And  as 
we  take  our  way,  we  develop  habits  of  meeting  the  sorrow  and 
disappointments  that  come;  the  anxiety,  criticism,  success,  fail- 
ure, illness,  poverty  and  what  not. 

Some  individuals  habitually  face  the  issues  of  life,  whether 
large  or  small,  and  habitually  overcome  difficulties  for  themselves 
and  for  other  people.  They  are  described  by  the  psychiatrists 
as  being  grown  up,  or  psychologically  evolved. 

Others  follow  the  course  of  least  resistance;  never  face  their 
problems;  are  thoughtless  and  inconsiderate  in  their  demands; 

145 


146  OBSTETRICAL  NURSING 

are  unable  to  make  decisions  and  accordingly  live  upon  the  men- 
tal and  moral  strength  of  others.  Such  people  are  referred  to  as 
being  infantile,  or  psychologically  undeveloped.  They  are  not 
unlike  the  baby  who  gets  "what  he  wants  when  he  wants  it"  by 
the  unreasoning  method  of  screaming  and  pounding  upon  his 
high  chair  with  a  spoon.  He  is  scarcely  more  irresponsible  than 
the  hysterical  adult  who  gains  her  point  by  developing  a  head- 
ache or  fainting,  flying  into  a  rage  or  tearing  her  clothes  and 
smashing  china.  Such  people  make  little  or  no  adjustment  to 
unsatisfactory  conditions  and  have  poor  capacity  for  endurance 
or  sacrifice. 

With  not  a  few  women  this  poor  capacity  is  a  result  of  life- 
long indulgence  or  protection  by  unwise  parents,  and  they  never 
reason  out  the  question  of  obligation  or  responsibility  because 
they  never  have  to.  Everything  is  done  for  them.  All  rough 
places  are  so  consistently  smoothed  out  that  they  never  entertain 
the  idea  that  effort  or  adaptation  on  their  part  could  possibly  be 
in  order. 

There  are  others  who  cherish  trouble,  make  difficulty  where 
there  need  be  none  and  steadfastly  refuse  to  acknowledge  good 
fortune  or  see  the  silver  lining.  This  is  their  method  of  secur- 
ing attention,  much  as  the  baby  cries  or  screams  to  the  same  end. 

Between  these  extreme  types  are  ranged  people  who  display 
innumerable  shadings  and  degrees  of  psychological  development. 
Some  cope  satisfactorily  with  their  life  situation  because  that 
situation  is  neither  difficult  nor  beyond  their  capacity  for  ad- 
justment. Others  need  a  little  bolstering  up  now  and  then  to 
bridge  over  the  gap  between  the  demands  made  upon  them  and 
their  ability  to  meet  these  demands.  Still  others  have  to  be  lit- 
erally carried  when  disaster  overtakes  them,  or  they  break  down. 

As  might  be  expected,  our  ability  to  stand  the  big  tests  or 
strains  that  may  come  to  us;  our  manner  of  meeting  them  and 
their  effect  upon  us  depend  very  largely  upon  how  we  have 
habitually  met  the  lesser  trials  that  have  come  to  us  previously, 
how  we  have  habitually  adjusted  ourselves  to  the  experiences  of 
life.  For  after  all  the  test  of  life  is  a  measure  of  one 's  capacity 
for  adaptation  to  these  experiences  and  to  surroundings. 

The  strain  that  measures  our  ability  to  adapt  ourselves  may 


MENTAL  HYGIENE  OF  EXPECTANT  MOTHER    147 

be  one  big  stroke  or  it  may  be  a  long  drawn  out  trial  which 
would  be  of  small  consequence  were  it  of  short  duration.  It  is 
the  persistency  and  the  monotony  of  a  lesser  care  that  so  often 
wears  away  the  rock  of  our  endurance. 

If  a  strain  proves  to  be  too  much  for  our  adaptive  capacity, 
and  we  break  down  under  it,  our  manner  of  breaking  will  be 
characteristic  of  us,  or  an  accentuation  of  what  might  have  been 
called  our  bendings  under  lesser  difficulties  in  the  past. 

The  expectant  mother  is  no  exception  to  these  general  prin- 
ciples. She  does  not  develop  nervous  breakdowns  either  more 
or  less  frequently  than  the  non-pregnant  woman  who  is  under 
an  equal  strain.  She  is  merely  a  human  being  whose  adaptive 
capacity  is  being  tested.  But  the  test  is  severe  for  there  is,  per- 
haps, no  greater  strain  upon  the  adaptive  capacity  of  a  human 
being  than  that  to  which  a  woman  is  subjected  during  pregnancy, 
confinement  and  the  months  directly  following  the  birth  of  a 
child.  She  maj'  be  expected  to  meet  this  strain  just  as  she  would 
meet  another  equally  great  demand  upon  her  adaptive  ca- 
pacity. 

Otherwise,  pregnancy  of  itself  does  not  affect  the  brain  or  the 
mind,  any  more  than  it  affects  the  kidneys,  for  example.  But 
like  the  kidneys,  the  brain  or  the  mentality  may  have  difficulty 
in  coping  with  the  additional  strain  that  is  put  rpon  it  during 
pregnancy,  and  if  the  strain  is  greater  than  the  ability  to  func- 
tion in  either  case  there  is  likely  to  be  a  breakdown. 

It  is  now  generally  believed,  therefore,  that  there  is  no  psy- 
chosis which  is  typical  of  pregnancy.  But  that  during  pregnancy 
one  may  see  all  types  of  neuroses  and  psychoses  which  are  fre- 
quently associated  with  other  severe  strains  upon  the  individual. 
We  see  depressions,  excitement,  paranoid  trends,  delusional  and 
hallucination  states,  hypochondriasis,  obsessive  fears,  anxiety  at- 
tacks, hysterical  manifestations  as  well  as  the  so-called  "neurotic 
vomiting. ' ' 

Aside  from  the  delirium-like  experiences  often  associated 
with  the  toxemias  of  pregnancy,  none  of  the  above  mentioned 
conditions  are  referable  to  any  disturbance  of  the  physiologic  or 
metabolic  functioning  of  the  patient,  so  far  as  science  can  dem- 
onstrate.   They  are  merely  accentuations  of  poor  habits  of  ad- 


148  OBSTETRICAL  NURSING 

justment  to  difficulties,  which  the  patient  has  betrayed  aU  her 
life. 

The  psychoses  of  pregnancy  and  the  puerperium  require  skil- 
ful handling  and  the  nurse  is  not  called  upon  to  care  for  them 
except  under  the  constant  supervision  of  a  physician. 

She  is,  however,  constantly  brought  face  to  face  with  facts 
of  fear  and  worry  and  conflicting  desires  which  play  a  tremen- 
dous role  in  the  well-being  of  the  patient  during  the  months  of 
pregnancy  and  confinement.  The  chief  source  of  happiness  and 
of  unrest  is  the  mother 's  attitude  toward  the  coming  of  the  baby. 
Just  here  it  may  be  helpful  to  have  a  word  about  what  is 
meant  by  "conflict"  and  the  "mechanism"  which  produces  it. 
As  a  starting  point  there  must  be  a  recognition  of  the  fact  that 
the  deepest  and  most  influential  feminine  instinct  is  maternal — 
the  desire  to  have  and  care  for  a  child.  It  is  primal.  It  has 
been  in  women  since  the  dawn  of  Creation  and  although  in  many 
women  it  is  put  down,  stifled  or  complicated  by  other  desires, 
it  cannot  be  destroyed.  Not  a  few  women  deny  this  instinct,  but 
back  of  their  denial  is  some  reason,  conscious  or  unconscious, 
which  is  not  harmonious  with  the  idea  of  motherhood.  The 
woman  may  be  selfish,  for  example;  she  may  be  vain  and  not 
want  to  lose  her  grace  and  charm  through  pregnancy. 

When  some  such  feeling  is  strong  it  conflicts  with  the  deeper 
one  of  maternalism  and  there  is  a  lack  of  harmony  or  a  "con- 
flict." It  is  just  that — a  conflict  or  struggle  between  two  emo- 
tions and  the  result  is  a  state  of  mental  unrest.  A  homely  com- 
parison might  be  found  in  the  digestive  disturbance  which  may 
follow  an  effort  to  cope  with  two  incompatible  articles  of  food 
at  the  same  time.  The  patient  may  have  nausea,  vomiting,  pain 
or  even  more  severe  symptoms.  The  severity  of  the  symptoms 
and  their  effect  upon  the  patient  depend  somewhat  upon  the 
average  vigor  or  stability  ordinarily  displayed  by  the  digestive 
tract  under  a  lesser  strain.  People  with  so-called  delicate  diges- 
tions may  be  greatly  upset  by  combinations  of  food  which  others 
are  able  to  cope  with  and  suffer  little  or  no  inconvenience. 

When  a  well  evolved  individual  has  a  desire  which  results 
from  our  culture  or  civilization  (a  wish  to  preserve  her  grace 
or  her  luxuries,  for  example),  that  is  in  conflict  with  a  deeper 


MENTAL  HYGIENE  OF  EXPECTANT  MOTHER    149 

primal  instinct,  she  will  often  be  able  to  reason  out  the  situation, 
and  in  the  case  of  approaching  motherhood,  decide  that  the  baby 
is  worth  any  sacrifice,  any  inconvenience,  and  go  joyfully 
through  her  period  of  expectancy.  She  will  glory  in  the  con- 
sciousness of  her  ability  to  realize  the  supreme  purpose  of  a 
woman's  creation.  In  other  words  she  adjusts  herself  to  the 
situation,  harmonizes  the  discordant  desires  and  is  mentally  un- 
disturbed. 

A  less  well  evolved  woman,  like  a  person  with  a  delicate,  easily 
upset  digestive  tract,  will  have  difficulty  in  making  an  adjust- 
ment— in  harmonizing  her  instinctive  desire  for  motherhood  and 
her  acquired  desire  for  comfort,  attention  and  the  things  de- 
manded by  convention.  The  conflict  may  be  violent  enough  to 
greatly  upset  her.  This  is  particularly  true  if  the  demands  of 
our  cultural  state  make  it  necessary  for  the  patient  to  keep  this 
turmoil  below  the  surface  with  no  safety  valve  to  relieve  the 
pressure. 

This  problem  of  the  motlier's  attitude  toward  the  coming  of 
the  baby  is  very  general  and  varied  as  well.  The  mothers  of 
families  already  large  and  poverty  stricken  are  usually  quite 
frank  in  expressing  their  dismay  over  the  expected  birth  and 
lament  the  prospect  of  this  extra  burden,  but  at  the  same  time 
they  decide  to  make  the  best  of  it  and  they  succeed  in  making 
a  pretty  satisfactory  adjustment.  Moreover,  they  do  not  feel 
the  necessity  for  concealing  their  feelings  or  do  not  "repress" 
them,  and  accordingly  find  some  relief  in  being  candid. 

The  mothers  of  the  middle  and  upper  classes,  however,  are 
often  surrounded  by  an  atmosphere  of  conventional  codes  that 
are  stifling  to  mental  honesty.  Accordingly  they  are  less  genu- 
ine in  expressing  their  true  attitude  toward  the  coming  child. 
To  many  of  them — the  selfish,  self -centered  type — the  new  baby 
will  bring  inconvenience  rather  than  hardship.  The  importance 
of  their  ego  will  be  dimmed.  There  will  be  a  cutting  down  of 
luxuries  and  of  freedom  for  social  activities,  and  increased  re- 
sponsibility with  closer  confinement  to  the  home.  And  while 
they  give  utterance  to  joy  and  pleasure  over  the  prospect  of  hav- 
ing a  baby,  this  does  not  quite  reflect  their  inmost  feelings. 

Not  a  few  women  find  an  outlet  for  the  tension  caused  by 


150  OBSTETRICAL  NURSING 

their  conflict  by  being  fretful  and  irritable  or  through  conduct 
which  they  would  have  displayed  if  annoyed  or  chagrined  about 
something  other  than  the  approaching  birth  of  a  child.  Because 
of  this  outlet  they  are  not  so  likely  to  break  down. 

It  is  by  no  means  the  role  of  the  nurse  to  pry  into  the  affairs 
of  her  patients,  but  she  can  often  become  the  avenue  of  ventila- 
tion for  a  patient  suffering  from  a  mental  conflict,  and  with  very 
happy  results.  For  one  of  the  most  helpful  things  that  such  a 
person  can  do  is  to  talk,  and  little  by  little  bring  out  and  put 
into  words  the  buried  thoughts,  dreads  or  shame  that  may  be 
causing  the  conflict.  Very  often  the  listener  will  say  surpris- 
ingly little  and  will  express  no  definite  opinions,  but  by  a  sympa- 
thetic, responsive  attitude  encourage  the  worried  person  to  pour 
out  the  content  of  her  mind. 

Another  source  of  unrest  in  the  mind  of  the  expectant  mother, 
especially  during  her  first  pregnancy,  is  the  fear  of  death  during 
labor,  or  the  development  of  complications.  She  is  reluctant  to 
speak  of  these  things  to  her  husband,  family  or  friends,  lest  they 
laugh  at  her  or  regard  her  as  a  coward  at  the  prospect  of  pain. 
Or  she  may  be  unwilling  to  distress  those  who  love  her  by  ad- 
mitting her  fear. 

Fear  of  death  and  disease  are  very  common  traits  and  equally 
common  is  the  hesitancy  we  all  have  in  acknowledging  them. 
And  so  the  patient  keeps  these  things  to  herself  and  turns  them 
over  and  over  in  her  mind;  buries  them  and  tries  to  put  them 
out  of  her  thoughts.  But  they  stick.  Her  fear  and  her  dread 
color  everything  that  she  hears,  and  very  often  and  unwittingly 
her  friends  and  relatives  make  matters  worse  by  recounting  the 
unhappy  experiences  of  other  mothers  that  they  have  known. 
At  the  same  time  these  communicative  friends  do  not  tell  of  the 
immeasurably  greater  number  of  women  who  have  come  through 
safely,  nor  does  the  patient  dwell  upon  these  in  her  mind.  She 
remembers  the  women  who  had  convulsions  or  fever  or  a  hemor- 
rhage, or  the  one  who  died. 

The  nurse  who  sees  the  human  being  beyond  the  obstetrical 
case  will  appreciate  the  pain  which  such  a  conflict  causes  and 
by  being  sympathetic  and  responsive  will  try  to  make  it  easy  for 
her  patient  to  talk  it  over.    The  patient  should  invariably  find 


MENTAL  HYGIENE  OF  EXPECTANT  MOTHER    151 

her  nurse  ready  to  listen  and  to  give  assurances  of  the  proved 
value  of  the  pi-ecautions  that  are  being  taken  to  safeguard  her 
and  her  baby.  Fur  not  a  few  women  are  torn,  not  alone  by  the 
fear  that  things  will  go  wrong  with  themselves,  but  with  the  fear 
that  harm  may  come  to  the  baby  that  they  long  to  take  into  their 
arms  and  keep. 

Other  women  are  upset  because  of  a  habitual  inability  to  make 
decisions  that  will  l)ring  al)out  a  marked  change  in  their  lives. 
They  find  it  difficult  to  accept  pregnancy  because  its  consum- 
mation will  definitely  alter  their  state.  Life  may  prove  to  be 
more  satisfactory  because  of  the  baby,  or  it  may  be  less  so.  But 
in  any  event  it  cannot  be  the  same  and  they  dread  making  an 
irrevokable  change. 

Still  another  cause  of  distress  is  the  current  belief  as  to 
hereditary  influence,  and  the  possible  effect  upon  the  unborn 
child  of  unsuccessful  attempts  at  abortion  which  the  patient  has 
made  early  in  her  pregnancy.  Every  family  has  its  skeleton  of 
a  relative  who  is  "queer,"  feeble-minded,  epileptic  or  who  has 
died  in  a  sanitarium  or  state  hospital  for  the  insane.  The  fear 
that  the  child  may  "strike  back"  to  one  of  these  individuals,  and 
suffer  retardation  in  his  mental  development,  often  amounts  to 
little  less  than  an  obsession. 

The  nurse  may  often  dispel  such  an  anxiety  by  drawing  upon 
even  her  slender  knowledge  of  embryology'  and  reassure  her  pa- 
tient that  we  know  very  little  about  inheritance,  but  that  the 
evidence  is  that  environment  and  early  training  are  such  impor- 
tant determining  factors,  that  a  child  is  more  likely  to  be  af- 
fected by  the  example  and  guidance  of  his  parents  during  his 
first  few  years  than  through  transmission  from  their  blood. 

Attempted  abortions  during  the  early  months  of  pregnancy 
are  more  common  than  is  generally  supposed.  Of  their  effect 
upon  the  offspring  we  know  very  little.  We  do  know,  however, 
that  an  attempt  to  produce  an  abortion  often  gives  rise  to  a  good 
deal  of  secret  worry  on  the  part  of  the  expectant  mother.  It  is 
the  nucleus  of  many  a  vague  depression  during  pregnancy,  not 
only  because  of  remorse  over  wrong-doing,  but  also  because  of 
fear  that  the  child  who  is  coming,  in  spite  of  the  attempt  to 
destroy  him,  may  suffer  the  consequences.     This  is  another  of 


152  OBSTETRICAL  NURSING 

the  anxieties  which  the  patient  can  seldom  bring  herself  to  dis- 
cuss with  her  family  or  even  with  her  physician  But  it  so  oc- 
cupies her  mind  that  she  may  allude  to  it,  in  a  roundabout  way, 
to  the  nurse  who  becomes  her  constant  companion,  as  though 
describing  the  act  of  a  friend.  The  nurse  who  reads  between 
the  lines  may  often  relieve  a  serious  tension  caused  in  this  way 
by  discussing  the  matter  casually  and  impersonally.  Above  all 
she  must  not  assume  an  attitude  of  disapproval,  for  it  is  not 
within  her  province  to  go  into  the  ethics  or  morality  of  the  act. 
Her  function  at  this  time  is  solely  to  give  the  patient  an  oppor- 
tunity to  ventilate  her  thoughts. 

Another  real  cause  of  worry  during  pregnancy  is  the  pa- 
tient 's  fear  of  her  own  inadequacy  to  care  for  and  to  rear  a  child 
in  the  best  possible  manner.  The  idea  of  assuming  the  physical 
care  and  the  moral  guidance  of  another  human  being  is  often  lit- 
tle less  than  terrifying  to  a  young  woman  whose  responsibilities 
in  the  past  have  been  shared  or  carried  by  some  one  else.  Or  to 
the  one  who  has  gone  through  life  hunting  for,  and  exaggerating, 
the  difficulties  in  a  situation,  before  attempting  to  meet  it;  and 
perhaps  to  the  one  who  is  habitually  conscientious  in  all  of  her 
relations  with  other  people. 

Still  another  type,  and  one  which  presents  a  much  simpler 
situation,  is  the  expectant  or  young  mother  who  is  scarcely  suf- 
fering from  a  mental  strain,  but  has  a  little  let-down  in  her 
customary  poise  and  self-control,  such  as  we  so  often  see  in  con- 
valescents and  chronic  invalids. 

Pregnancy,  labor,  and  the  puerperium  are  normal  physiologi- 
cal processes,  it  is  true,  but  they  impose  a  physical  tax  and  the 
patient  is  sometimes  physically  tired  and  after  labor  may  suffer 
something  akin  to  surgical  shock. 

The  physical  weariness  may  be  due  to  an  insufficiency  on  the 
part  of  some  one  of  the  internal  secretions.  But  in  any  event 
the  patient  feels  tired  and  may  show  the  same  sensitiveness  or 
irritability  that  any  of  us  show  when  tired  and  exhausted  and 
she  will  merit  considerable  forbearance  on  the  part  of  those  who 
surround  her. 

But  when  we  understand,  even  faintly,  the  conflicts  which 
are  possible  in  the  mental  life  of  the  expectant  mother — the 


MENTAL  HYGIENE  OF  EXPECTANT  MOTHER    153 

incompatibility  of  her  age-old  maternal  instinct  and  the  desires 
born  of  our  culture  and  civilization,  it  is  not  difficult  to  see  that 
her  adaptive  capacity  may  be  sorely  tested. 

The  cause  of  her  trouble  is  not  apparent  to  the  patient's 
associates  but  they  are  aware  of  its  manifestations  in  the  shape 
of  moods,  temper  tantrums,  strange  conduct  and  all  sorts  of 
nervous  and  mental  symptoms.  If  such  a  patient  does  not  get 
relief  through  talking  things  over,  but  continues  to  brood  and 
worry  alone — to  repress  the  cause  of  the  conflict — she  may  not 
be  sufficiently  adaptive  to  endure  its  ravaging  effects,  and  have 
a  nervous  or  mental  breakdown  as  a  result. 

It  is  hoped  that  the  nurse  may  understand  from  this  discus- 
sion that  the  conflicting  thoughts  which  her  patient  does  not  dis- 
cuss, but  buries  and  keeps  below  the  surface  of  her  mind,  are 
the  factor  that  works  harm  in  her  mental  life.  If  the  nurse  can 
get  her  patient  to  ventilate  these  thoughts,  they  will  be  robbed 
of  much  of  their  power  to  injure.  But  this  patient,  like  any  one 
else,  will  talk  freely  only  when  she  talks  spontaneously  and  she 
will  do  this  only  when  she  senses  in  her  nurse  a  sympathy  and 
a  sincere  concern  over  her  troubles. 

Accordingly,  the  nurse  should  try  to  so  attune  herself  as  to 
be  receptive  to  evidences  of  the  patient's  moods  and  impulses, 
and  possibly  from  a  chance  remark  get  a  clue  to  the  repressed 
desires  which  are  working  harm.  She  will  then  be  able  to  meet 
the  patient  on  that  ground. 

It  is  not  that  the  relief  of  the  patient  by  means  of  mental 
catharsis  is  necessarily  a  nurse's  function.  It  is  simply  that  a 
patient  suffering  from  a  conflict  should  talk  freely  to  some  one, 
it  does  not  matter  who,  and  by  virtue  of  the  long  hours  which 
they  spend  together,  the  nurse  very  often  happens  to  be  that 
some  one.  People  do  not  ordinarily  find  it  easy  to  lay  bare  their 
inmost  thoughts  before  the  members  of  their  family  and  the 
patient  may  not  discuss  her  conflict  with  her  physician,  which 
of  course  is  the  ideal,  because  his  visits  are  relatively  short  and 
do  not  favor  the  ambling,  desultory  conversation  into  which  the 
nurse  and  patient  may  so  easily  drift. 

On  the  other  hand,  the  nurse  must  not  look  for  trouble,  in 
order  to  be  useful,  nor  by  the  slightest  intimation  give  her  pa- 


154  OBSTETRICAL  NURSING 

tient  an  idea  that  it  is  a  common  practice  among  expectant 
mothers  to  worry,  be  fearful  or  alarmed.  If  the  patient  displays 
these  emotions  the  nurse  must  be  ready,  but  she  must  not  be 
suggestive.  Her  attitude  must  be  entirely  passive  for  she  is 
simply  a  receptacle  into  which  the  patient  may  pour  her  con- 
flicting thoughts.    But  the  receptacle  must  be  always  available. 

The  positive  course  which  the  nurse  may  take  is  to  be  un- 
failingly hopeful  and  courageous  and  take  it  for  granted  that 
her  patient  is  filled  with  joy  and  pride  over  her  pregnancy.  The 
gratification  is  tliere  by  instinct,  but  it  may  be  so  buried  and 
complicated  by  other  emotions  that  the  patient  is  not  wholly 
aware  of  it.  It  may  be  surprisingly  clarifying  for  the  nurse  to 
say  quite  simply,  "But,  after  all,  it  is  a  wonderful  thing  to  have 
a  baby  and  you  are  proud  and  glad  that  he  is  coming.  He  will 
be  worth  any  sacrifice." 

If  the  nurse  will  so  far  put  herself  in  the  patient 's  place  that 
she  is  glad,  sincerely  glad,  that  the  baby  is  coming,  this  attitude 
will  communicate  itself  to  the  expectant  mother.  Happiness  and 
enthusiasm  are  very  infectious. 

To  sum  it  all  up :  The  expectant  mother  who  habitually 
has  not  made  satisfactory  adjustments  during  her  life  may  be 
bending  under  a  mental  burden  that  is  a  little  heavier  than  her 
slender,  unevolved  powers  can  bear.  The  nurse's  part  is  to 
recognize  this  possibility  and  realize  that  while  she  cannot  at- 
tempt to  correct  the  difficulty  she  can  be  a  prop  by  simply  being 
optimistic  and  reassuring.  A  patient  who  may  be  suffering  from 
a  mental  conflict  is  often  saved  from  a  breakdown  by  little  more 
than  a  ready  sympathy  which  is  born  of  understanding. 


CHAPTER  VIII 

THE   PREPARATION   OF   ROOM,   DRESSINGS   AND 
EQUIPMENT  FOR  HOME  DELIVERY 

It  sometimes  devolves  upon  the  nurse  to  give  advice  in  se- 
lecting and  preparing  the  room  to  be  used  for  a  home  confine- 
ment, and  very  often  to  help  the  prospective  mother  in  preparing 
and  assembling  adequate  equipments  for  the  delivery  and  for  the 
care  of  herself  and  the  baby  afterwards. 

Under  such  circumstances  the  nurse  must  feel  under  compul- 
sion to  do  all  in  her  power  to  make  the  home  delivery  satisfac- 
tory, from  the  standpoint  of  the  patient's  happiness  and  con- 
tentment and  from  the  standpoint  of  surgical  cleanliness  and 
efficiency  as  well,  so  that  normal  cases,  at  least,  may  be  attended 
with  reasonable  safety  at  home. 

We  know  that  the  deaths,  incident  to  childbirth,  throughout 
this  country  at  large,  have  not  declined  during  the  past  decade, 
in  spite  of  improved  obstetrical  methods  and  skill  and  the  large 
percentage  of  recoveries  in  hospitals  where  they  are  applied.  In 
the  homes,  in  general,  young  mothers  continue  to  die  in  dis- 
tressingly large  numbers,  chiefly  from  infection,  which  we  know 
is  largely  preventable.  Apparently,  then,  in  some  important 
particulars  the  conditions  surrounding  the  majority  of  home 
deliveries  are  still  such  as  to  be  almost  a  menace  to  life  and 
health.  And  as  it  is  manifestly  impossible  for  all  obstetrical  pa- 
tients to  be  cared  for  in  hospitals,  home  deliveries  need  to  be 
made  safer,  which  virtually  means,  made  cleaner. 

This  grave  need  cannot  be  dismissed  by  the  nurse  as  some- 
thing outside  of  her  province.  She  may  aid  greatly,  and  there- 
fore is  under  obligation  to  do  so,  in  making  home  confinements 
surgically  clean,  by  being  conscientious  and  thoughtful  and 
thorough  in  her  preparations  and  assistance. 

A  relatively  small  percentage  of  obstetrical  patients  require 
operative  assistance,  but  without  a  single  exception  they  all  re- 

155 


156  OBSTETRICAL  NURSING 

quire  cleanliness;  cleanliness  of  appliances  and  cleanliness  of 
methods. 

As  the  first  labor  is  usually  longer  and  more  difficult  than 
later  ones,  and  the  percentage  of  lacerations  and  operative  inter- 
ference is  higher,  primiparae  should  be  delivered  in  hospitals 
when  possible,  as  well  as  all  cases  presenting  any  complication  or 
abnormality.  But  women  who  are  normal,  particularly  multi- 
parae,  and  these  constitute  the  vast  majority  of  obstetrical  pa- 
tients, should  be  able  to  remain  at  home  in  safety. 

In  most  instances  the  patient  who  is  to  be  delivered  at  home 
will  have  to  occupy  her  accustomed  room  and  there  is  no  alterna- 
tive. Should  there  be  a  choice  of  rooms,  however,  one  should 
be  selected  that  is  cool  and  shady,  if  the  confinement  takes  place 
during  the  summer,  but  bright  and  sunny  for  occupancy  during 
most  of  the  year;  it  should  be  conveniently  near  a  bathroom  if 
possible,  and  have  an  adjoining  room  for  the  nurse  and  baby 
to  occupy. 

The  arrangement  and  furnishings  of  the  room  will  not  of 
necessity  vary  greatly  from  those  of  a  room  which  is  to  be 
occupied  by  any  patient.  Carpets,  upholstered  furniture,  heavy 
draperies  and  curtains  are  no  more  suitable  in  this  than  in  any 
patient's  room. 

The  ideal  is :  A  room  with  a  washable  floor  with  small,  light 
rugs;  freshly  laundered  curtains  at  the  windows;  a  single,  brass 
or  iron  bedstead,  about  30  inches  high,  with  a  firm  mattress,  and 
so  placed  as  to  be  accessible  from  both  sides  and  with  the  foot  in 
a  good  light,  either  by  day  or  by  night ;  a  bedside  table  and  two 
others  (folding  card  tables  are  a  great  convenience)  ;  a  bureau; 
a  washstand,  unless  there  is  a  bathroom  on  the  same  floor;  one 
or  two  comfortable  chairs,  two  or  three  straight  chairs  and  a 
couch  or  chaise  longue,  all  of  which  should  be  of  wood  or  wicker 
or  covered  with  freshly  laundered  chintzes. 

Barrenness  is  not  only  unnecessary  but  is  to  be  avoided,  for 
the  room  should  be  as  cheerful  and  pretty  as  is  compatible  with 
cleanliness.  There  is  usually  no  objection  to  pictures  on  the  wall, 
but  the  room  should  be  free  from  useless,  small  articles  which 
are  dust  catchers,  give  the  nurse  unnecessary  work,  and  occupy 
space  needed  for  other  things.    Between  such  a  room  as  this  and 


THE  PREPARATION  OF  ROOM  157 

the  one  which  the  nurse  finds  must  be  used,  there  may  be  a  dis- 
maying difference,  and  so  once  more  siie  must  exercise  her  in- 
genuity and  resourcefulness;  cliange  and  improve  whei-e  it  is 
possible  and  make  tiie  best  of  conditions  that  cannot  be  altered, 
for  the  baby  i>j  coming  and  the  mother  must  be  safeguarded 
from  infection  and  other  disaster,  no  matter  what  the  room  is 
like. 

Much  as  we  should  like  ideally  to  equip  and  prepare  every 
room  to  be  used  for  a  home  confinement,  we  cannot  overlook  the 
importance  of  having  preparations  made  witii  as  little  disturb- 
ance as  possible  to  the  patient  and  her  household.  Preparations 
made  with  bustle  and  ostentation  are  suggestive  of  inefficiency ; 
are  bad  for  the  patient,  frequently  causing  her  great  alarm,  and 
in  the  main  had  better  be  omitted.  The  nurse  who  is  able  to 
go  into  a  home  quietly  and  unobtrusively  and  accept  what  she 
finds,  even  carpets  and  draperies,  and  still  do  clean  work,  is 
doing  better  nursing  than  the  one  who  arranges  a  faultless  room 
but  upsets  her  patient  and  disrupts  the  household  in  the  process. 

Common  sense,  judgment  and  tact,  then,  will  sometimes  be 
as  important  in  preparing  a  room  for  home  delivery  as  are  wash- 
able floors,  curtains  and  furniture. 

While  we  do  not  advise  nor  elect  to  have  carpets,  draperies 
and  upholstery  in  a  delivery  room,  we  know  that  they  need  not 
menace  the  patient's  welfare  if  all  details  of  the  work  about  the 
patient,  herself,  are  scrupulously  clean.  That  is  the  one  point 
which  the  nurse  must  bear  constantly  in  mind,  the  paramount 
importance  of  clean  work  about  the  patient. 

The  room  should  be  given  a  thorough  housecleaning  about 
two  weeks  before  the  expected  date  of  delivery.  If  there  is  car- 
pet on  the  floor,  there  should  be  a  large  canvas  or  rubber,  or  an 
abundance  of  newspapers  available  to  protect  it,  about,  and 
under  the  bed;  and  if  the  bed  is  of  wood,  the  sideboards  and 
foot  should  be  covered  to  protect  them  from  injury  by  soap, 
water  and  solutions  which  may  be  spattered  or  spilled  during 
labor.  If  the  bed  is  low,  there  should  be  four  solid  blocks  of 
wood  prepared,  upon  which  to  elevate  it,  after  removing  the  cas- 
ters, and  it  is  also  a  good  plan  to  have  a  large  board,  or  table 


158  OBSTETRICAL  NURSING 

leaves,  in  readiness  to  slip  under  the  mattress  to  make  it  firm, 
particularly  if  the  bed  is  soft  or  sinks  in  the  middle. 

So  much  for  the  room. 

In  preparing  the  dressings  and  assembling  the  various  ar- 
ticles to  be  used  the  nurse  will  do  well  to  remember  that,  although 
it  is  possible  to  use  a  number  of  things  during  labor,  it  is  also 
possible  to  do  excellent  work  with  a  meagre  equipment  supple- 
mented with  a  cool  head  and  ingenuity  and  training  and  above 
all,  an  exacting  conscience.  The  average  nurse  will  wish,  usu- 
ally, to  follow  a  median  course  in  her  preparations,  having  every- 
thing at  hand  that  will  facilitate  the  work;  be  adequately 
equipped  for  emergencies  but  not  burdened  with  non-essentials. 

As  the  wishes  and  methods  of  different  doctors  vary,  the  ar- 
ticles needed  in  assisting  them  must  of  necessity  vary  also.  But 
in  addition  to  the  instruments  which  will  be  used,  the  following 
articles  will  meet  the  ordinary  requirements  during  a  home  con- 
finement, and  many  of  them,  or  adequate  substitutes,  are  to  be 
found  in  the  average  household. 

For  the  Mother  and  the  Delivery: 

Plenty  of  sheets,  pillow  cases,  towels  and  night  gowns. 

4  or  6  T.  binders  or  sanitary  belts. 

1  piece  rubber  sheeting  or  oilcloth,  1  x  II/2  yards. 

1  piece  rubber  sheeting  or  oilcloth,  2  x  l^/^  yards. 

Two  or  three  dozen  safety  pins. 

Hot  water  bag  with  flannel  cover. 

1  two-quart  fountain  syringe. 

1  douche  pan. 

1  bed  pan. 

2  covered  slop  jars  or  covered  pails. 

3  basins,  about  16,  14  and  12  inches  in  diameter. 

2  stiff  nail  brushes,  nail  scissors  and  file  or  orange  stick. 

3  agate  or  enamel  pitchers,  holding  at  least  one  quart  each. 
Medicine  glass. 

Medicine  dropper. 

2  bent  glass  drinking  tubes 

100  bichloride  tablets. 

4  oz.  chloroform. 

4  oz.  boric  acid  powder. 

4  oz.  green  soap. 

1  pint  grain  alcohol. 

Small  jar  of  vaseline  to  be  sterilized. 


THE  PREPARATION  OF  ROOM  159 

Lard,  olive  oil,  vaseline  or  albolene  to  oil  baby. 
Roll  adhesive  plaster  1  inch  wide. 
1  pkg-.    absorbent    cotton. 
1  thermometer. 

In  addition  to  these,  a  certain  supply  of  sterile  dressiup;s  will 
be  needed.  Complete  outfits  of  such  dressings,  sterilized  and 
ready  for  use,  may  be  obtained  from  any  one  of  a  number  of 
firms,  or  the  following  may  be  prepared  by  the  nurse  or  by  the 
patient,  under  the  nurse's  direction: 
Dressings: 

1  doz.  sterile  towels. 

5  or  6  doz.  perineal  pads. 

2  or  4  delivery  pads,  made  of  gauze  and  common  cotton  with  top 
laj'er  of  absorbent  cotton,  or  newspapers  covered  with  muslin. 

5  or  6  doz.  gauze  sponges. 

2  or  3  doz.  gauze  squares,  4  inches  square. 
4  or  5  doz.  cotton  pledgets. 

1  pr.  leggings,  made  of  canton  or  outing  flannel,  either  loose  fitting 
hose  or  a  yard  square  folded  diagonally  and  stitched.  (See  Fig. 
110.) 

3  sheets. 

6  pieces  cord-tie  of  bobbin  or  narrow  tape,  9  inches  long. 

These  may  be  put  up  into  packages  in  the  usual  manner, 
using  muslin  for  wrapping,  and  sterilized  in  the  patient's  home 
as  follows :  Fill  a  wash  boiler  about  I/4  full  of  water  and  fashion 
a  hammock  from  a  towel  or  strong  piece  of  muslin,  tied  securely 
W'ith  strings  at  each  end  and  hung  from  the  handles  so  that  the 
bottom  of  the  hammock  in  about  half  way  down  in  the  boiler. 
As  the  weight  of  the  dressings  makes  the  hammock  sag  low,  in 
the  middle,  it  is  usually  necessary  to  place  a  rack,  or  support  of 
some  kind,  in  the  bottom  of  the  boiler  to  hold  the  dressings  well 
above  the  bubbling  water,  at  the  point  where  they  hang  lowest. 
Pile  the  dressings  into  the  hammock,  cover  the  boiler  tightly  and 
keep  the  w-ater  boiling  vigorously  for  one  hour ;  dry  the  packages 
in  the  sun  or  by  placing  them  in  the  oven  for  a  few  moments,  and 
at  the  end  of  twenty-four  hours  repeat  the  sfeaming  and  drying 
process,  wrap  the  packages  in  a  clean  sheet  or  paper  and  put 
them  away  in  a  drawer  or  covered  box  where  they  should  remain 
until  time  to  prepare  for  the  delivery.  The  brushes,  douche  pan, 
irrigation-bag,  and  other  articles  which  must  be  surgically  clean 


160 


OBSTETRICAL  NURSING 


may  be  sterilized  in  the  same  way.  The  gloves  may  be  sterilized 
in  this  way  or  boiled  immediately  before  delivery.  If  sterilized 
by  steam,  the  gloves  should  be  thoroughly  dried,  dusted  with 
talcum  inside  and  out  to  prevent  them  from  sticking  together, 
and  may  be  wrapped  in  packages  or  placed  in  individual  cases 
(Fig.  42).  A  small  towel  or  piece  of  soft  muslin  and  a  ball  of 
gauze  containing  talcum  powder,  if  placed  in  the  case  and  ster- 


FiG.  42. — Gloves  with  cuffs  turned  up,  lying  with  small  towel  and 
powder  puff  of  gauze  and  talcum,  on  double  envelope  case  in  Avhich  they 
may  be  dry-sterilized.     (From  photograph  taken  at  the  Brooklyn  Hospital.) 

ilized  with  the  gloves,  are  often  a  convenience  to  the  doctor  in 
putting  on  the  gloves. 

The  newspaper  delivery  pads  offer  excellent  protection  and 
are  made  of  six  thicknesses  of  paper  covered  with  a  piece  of 
freshly  laundered  muslin,  Avhich  is  folded  over  the  edges  and 
basted  in  place.  (Fig.  43).  These  pads  may  be  made  virtually 
sterile  by  ironing  them  on  the  muslin  side  with  a  very  hot  iron, 
folding  the  ironed  surface  inside  without  touching  it;  again 
ironing  on  the  outside  and  wrapping  in  a  clean  muslin  or  sheet, 


THE  PREPARATION  OF  ROOM 


161 


also  recently  ironed,  and  putting  away  in  a  place  protected  from 
dust. 

The  nurse  herself  should  have : 

A  hypodermic  syringe  and  4  or  6  needles. 

1  pr,  long  forceps  to  use  as  dressing  forceps. 

1  pr.  short  forceps. 

1  pr.  bhmt  pointed  scissors. 

2  artery  clami^s. 

The  doctor  will  usually   supply  himself  with   any  articles 
needed  beyond  those  \vhieh  have  been  enumerated,  but  the  nurse 


Fig.  43. — Reverse  side  of  pad  made  of  newspajjers  and  old  muslin  to 
protect  bed  during  a  home  confinement.  If  muslin  is  held  in  place  with 
safety  pins  it  may  be  removed  easily,  washed  and  used  for  another  pad. 
(Courtesy  of  The  Maternity  Centre  Association.) 

should  be  sure  about  the  following  in  order  that  she  may  prepare 
whatever  he  may  lack  : 

Instruments  and  sutures. 
Hypodermic  tablets. 
Pituitrin  and  ergot,  or  ergotole. 
Gauze  packs. 
Gloves  and  sterile  gown. 
Rubber  apron. 

Filtered,  sterilized  salt  solution  and  infusion  needles- 
Chloroform  inhaler. 


162  OBSTETRICAL  NURSING 

In  planning  the  baby  clothes,  there  are  a  few  important  fac- 
tors to  bear  in  mind.  The  clothes  should  be  simple;  not  more 
than  twenty-seven  inches  long;  warm,  but  light  in  weight,  and 
large  enough  to  fit  loosely.  Like  the  dressings,  complete  layettes 
may  be  bought  outright,  but  if  the  mother  wishes  to  make  the 
little  garments  herself,  the  following  list  will  be  found  to  pro- 
vide an  adequate  supply  of  clothing  for  the  new  baby.  (See 
also  Fig.  159.) 

For  the  Baby,  Layette:  ^ 

2  to  4  doz.  diapers,  preferably  18  in,  square. 

3  flannel  bands,  6  or  8  inches  wide  and  27  in.  long  unhemmed. 

3  shirts,  size  No.  2,  of  cotton  and  wool,  silk  and  wool  but  not  all 
wool. 

4  flannel  petticoats,  Gertrude  style. 
4  flannel  nightgowns  or  slips. 

6  white  slips. 

3  knitted  bands  with  shoulder  straps,  to  use  after  the  cord  separates. 

Flannel  kimono  or  square,  one  yard,  to  be  used  as  extra  wrap  in 

cool  room. 
Cloak  and  cap  or  other  wrap  for  out-door  use. 
Additional  Articles  Which  Are  Needed  or  Useful  in  the  Care  of  the 
Baby: 
Bath  tub,  tin,  enamel,  agate  or  rubber. 
Drying  frames  for  shirts  and  stockings. 
Rubber  bath  apron. 

Flannel,  or  Turkish  toweling  bath  apron. 
Low  chair  without  arms. 
Low  table. 

Screen  to  protect  baby  during  bath. 
Rack  upon  which  to  hang  clothes  to  warm  during  bath. 
Scales,  with  beam  and  basket  and  scoop,  not  the  spring  variety. 
Hot  water  bag  and  cover. 
Crib,  basket  or  box,  to  be  used  as  bed. 
Folded  felt  pad,  blanket  or  hair  pillow  for  mattress. 
Rubber  or  oilcloth  to  cover  mattress. 
6  crib  sheets. 

1  thermometer. 

2  crib  blankets. 

Soft  towels  and  wash  cloths. 

An  old  blanket  to  be  used  for  bath  blanket, 

3  or  4  dozen  safety  jDins,  assorted  sizes. 
Castile  soap. 

Boric  acid  powder. 


THE  PREPARATION  OF  ROOM  163 

Olive  oil  or  albolene. 

Absorbent  cotton  pledgets,  preferably  sterile. 

Enamel  pail  and  cover. 

The  above  lists  of  dressings  and  articles  for  the  baby  can  be 
considerably  modified  and  still  be  satisfactory.  The  leaflet  of 
^'Advice  for  Mothers"  issued  by  the  Maternity  Centre  Associa- 
tion, New  York  City  (see  p.  429),  gives  a  somewhat  curtailed  list 
of  equipment  which  proves  to  be  adequate  and  within  the  means 
of  most  of  the  patients  with  whom  the  Association  works. 

It  is  usually  a  good  plan  for  the  nurse  to  advise  the  patient 
to  have  her  dressings  ready  by  about  the  end  of  the  seventh 
calendar  month,  and  the  layette  by  the  end  of  the  eighth  month. 
A  baby  born  before  this  time  would  probably  be  so  frail  that  it 
would  be  wrapped  in  cotton  and  not  require  the  clothes  ordi- 
narily prepared  for  a  full-term  baby. 


CHAPTER  IX 
COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY 

The  prenatal  care  which  was  outlined  in  an  earlier  chapter 
becomes  more  impressive  when  one  considers  the  disasters  which 
it  is  designed  to  prevent.  And  the  nurse  will  be  more  eager  and 
able  to  watch  her  patient  intelligently,  and  instruct  her  con- 
vincingly, if  she  appreciates  and  understands  something  of  the 
conditions  which  she  is  helping  to  avert.  She  will  give  more 
effective  nursing  care,  too,  when  complications  do  occur,  if  she 
gives  it  understandingly.  In  the  toxemias,  particularly,  the 
importance  of  the  nursing  care  looms  large,  for  it  is  painstaking 
attention  to  details  that  makes  this  care  so  nearly  a  matter  of 
life  or  death  to  the  patient. 

In  considering  the  complications  of  pregnancy,  the  nurse  in 
training  needs  a  reminder  that  hospital  experience  is  likely  to 
give  her  an  exaggerated  idea  of  the  relative  frequency  with  which 
they  occur.  This  is  due  to  the  fact  that  most  maternity  patients 
in  hospitals  are  there  because  they  are  known  to  be  abnormal 
in  some  way,  or  because  they  are  pregnant  for  the  first  time,  and 
first  pregnancies  are  more  likely  to  end  in  difficult  and  compli- 
cated labors  than  later  ones.  The  vast  majority  of  cases  run 
practically  uncomplicated  courses,  for  pregnancy,  labor  and  the 
puerperium  are  normal  physiological  processes.  It  is  extremely 
serious,  however,  to  allow  them  to  become  abnormal. 

Watchfulness  throughout  pregnancy,  then,  in  the  interest  of 
preventing  disaster,  cannot  be  too  insistently  advocated. 

Some  complications  that  are  watched  for  during  pregnancy 
are  peculiar  to  that  condition  alone,  and  these  may  be  divided 
into  three  general  groups: 

1.  The  premature  terminations  of  pregnancy,  which  are  desig- 
nated as  abortions,  niiscarriages  and  premature  labors. 

2.  Ante-partum  hemorrhages,   due  to   either  a  placenta  praevia 

164 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  165 

or  a  premature  separation  of  a  normally  implanted  placenta,  the  latter 
being  termed  "accidental  hemorrhage." 

3.  The  toxemias,  including  pernicious  vomiting,  pre-eelamptic 
toxemia,  eclampsia  and  possibly  nephritic  toxemia,  though  this  con- 
dition is  not  invariably  associated  with  pregnancy. 

There  are  other  conditions,  not  necessarily  inherent  to  the 
state  of  pregnancy,  but  which  should  be  detected  and  treated 
early,  since  their  development  coincidently  with  expectant 
motherhood  may  threaten  the  safety  of  the  patient  or  the  child, 
or  both.  Probably  the  most  serious  of  these  is  syphilis,  though 
gonorrhea,  impaired  kidneys,  heart  lesions,  tuberculosis  or  a 
general  state  of  poor  nutrition  also  may  prove  to  be  grave. 

Any  chronic,  organic  disease  is  likely  to  be  increased  in  se- 
verity by  the  strain  which  pregnancy  puts  upon  the  impaired 
organs,  in  common  with  the  rest  of  the  maternal  body.  But 
acute  diseases  usually  run  about  the  same  course  in  pregnant,  as 
in  non-pregnant  women,  except  when  an  infection  causes  an 
abortion,  the  shock  of  which,  in  turn,  reduces  the  patient's  re- 
sistance against  the  complicating  disease. 

As  we  consider  these  various,  dreaded  complications  which 
may  arise  during  pregnancy,  infrequent  though  they  be,  we  feel 
that  no  amount  of  effort  is  too  much  to  make,  if  we  can,  thereby, 
save  one  mother  or  one  baby  from  their  destructive  effects.  We 
are  stirred  by  the  urgency  of  preventing  a  premature  ending  of 
pregnancy,  for  example,  when  we  see  it,  not  so  much  as  simply 
another  obstetrical  emergency,  but  in  its  true,  tragic  light  as  the 
loss  of  an  infant  life  and  the  bereavement  of  an  expectant 
mother. 

PREMATURE  TERMINATIONS  OF  PREGNANCY 

The  termination  of  pregnancy  before  the  expected  time  is 
termed  an  abortion,  miscarriage,  or  a  premature  labor  or  birth, 
according  to  the  stage  to  which  the  pregnancy  has  advanced,  but 
there  are  wide  variations  in  the  accepted  meanings  of  these 
terms,  among  both  lay  and  medical  people. 

In  the  lay  mind,  abortions  are  usually  as.sociated  with  crim- 
inal practice  and  the  term  is  seldom  used,  while  miscarriage  is  a 
term  which  is  loosely  applied  to  all  deliveries  occurring  before 
the  child  is  viable,  or  before  the  seventh  month.     It  is  not  un- 


166  OBSTETRICAL  NURSING 

common,  however,  to  hear  the  term  abortion  used  to  designate 
the  termination  of  a  pregnancy  before  the  end  of  the  fourth 
month;  miscarriage,  one  which  occurs  between  the  end  of  the 
fourth  and  seventh  months,  and  premature  labor  as  one  which 
takes  place  any  time  after  the  seventh  month,  but  before  the 
expected  date  of  confinement. 

Medical  people,  on  the  other  hand,  seldom  use  the  term  mis- 
carriage, but  designate  as  abortions  all  terminations  of  preg- 
nancy which  occur  before  the  end  of  the  seventh  month ;  and  pre- 
mature labor,  those  occurring  from  that  time  until  the  estimated 
date  of  confinement.  It  is  these  meanings  which  will  be  intended 
when  the  terms  abortion  and  premature  labor  are  used  in  the 
following  pages. 

Abortions.  In  the  nature  of  things,  it  is  impossible  to  say 
how  often  abortions  occur.  They  sometimes  happen  so  early  in 
pregnancy  that  the  patient  is  unaware  of  the  accident;  or,  if 
she  does  know  of  it,  she  may  take  no  notice  of  it  or  regard  it  of 
so  little  consequence  that  she  does  not  consult  a  doctor;  while 
in  many  cases  it  is  intentionally  concealed  because  of  having  been 
criminally  induced.  But  such  information  as  is  available  sug- 
gests that  at  least  one  out  of  every  five  pregnancies  ends  in  an 
abortion. 

Since  the  ovum  is  insecurely  attached  to  the  uterus  until  the 
sixteenth  or  eighteenth  week,  an  abortion  is  more  likely  to  occur 
during  this  time  than  later,  while  of  this  period,  the  second  and 
third  months  seem  to  be  the  most  perilous. 

Abortions  are  less  likely  to  happen  during  first  pregnancies 
than  succeeding  ones;  they  occur  more  often  among  women 
over  thirty -five  years  old  than  in  younger  ones,  and  in  all  cases 
are  most  likely  to  take  place  at  the  time  when  the  menstrual 
period  would  fall  due  were  the  woman  not  pregnant.  Their 
frequency  probably  increases  with  the  number  of  pregnancies, 
because  of  the  tendency  of  muciparous  women  to  have  endome- 
tritis, which,  as  we  shall  see  later,  is  a  causative  factor. 

Causes.  There  is  a  variety  of  causes  of  abortions  and  mis- 
carriages, some  entirely  unavoidable,  but  many  which  are  pre- 
ventable, and  it  is  well  for  the  nurse  to  be  familiar  with  those 
which  operate  most  frequently,  as  follows: 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  167 

1.  Certain  abnormalities  of  the  developing  fetus  are  inconsistent 
with  life,  and  are,  therefore,  a  frequent  cause  of  abortion.  Dr.  Mall, 
of  Johns  Hopkins  University,  showed  after  years  of  investigation  that 
at  least  one-lliinl  of  tlie  embryos  obtained  from  abortions  were  mal- 
formed and  would  have  developed  into  monstrosities  had  they  lived  to 
term.  It  is  often  a  great  comfort  to  the  expectant  mother  who  loses 
her  baby  early  in  pregnancy  to  realize  that  had  she  carried  her  baby 
to  term  it  might  have  been  a  monster,  and  that,  therefore,  she  has  not 
lost  a  beautiful,  normal  child.  Just  why  these  abnonnalities  occur  is 
not  known,  nor  is  there  any  known  method  of  preventing  or  correcting 
them.  There  also  may  be  such  defects  in  the  placental  development,  that 
the  fetus  does  not  derive  sufficient  nourishment  to  continue  its  develop- 
ment, and  dies  very  early  as  a  result. 

2.  Abnormalities  in  the  generative  tract  may  cause  abortions, 
the  most  conunon  of  these  being  inllammation  of  the  uterine  lining 
and  a  mal-position  of  the  uterus  itself.  Gonorrheal  infection  is  a  fre- 
quent cause  of  such  an  inflammation,  which  so  alters  the  decidua  that 
a  satisfactory  implantation  of  the  ovum  is  impossible,  and  it  perishes 
from  lack  of  nourishment.  Uterine  misplacements,  particularly  retro- 
flexion and  prolapse,  are  important  causative  factors  in  abortions.  This 
is  because  the  malposition  interferes  with  the  blood  supply  and  lesions 
in  the  endometrium  result.  This  also  presents  an  unsatisfactory  lodge- 
ment for  the  ovum  and  it  cannot  survive  for  long. 

3.  Acute  infectious  diseases  all  tend  to  cause  the  death  of  the 
fetus  and  thus  cause  abortions.  Fetal  death  in  these  cases  is  believed 
to  be  due  to  the  transmission  of  toxic  material  from  mother  to  child, 
as  may  occur  also  in  such  poisoning  as  phosphorus,  lead  and  illumi- 
nating gas. 

4.  Mental  or  emotional  stress  may  be  the  cause  of  an  abortion, 
but  less  importance  is  attached  to  these  factors  to-day  than  formerly. 
There  is  an  occasional  case,  however,  which  can  be  explained  on  no 
other  grounds. 

5.  Physical  shocks,  such  as  falls,  blows  upon  the  abdomen,  jump- 
ing, tripping  over  carpets,  jars,  jolting  or  overexertion,  may  be  the  ex- 
citing cause  of  an  abortion  Avhere  there  is  a  marked  irritability  of  the 
uterine  muscles.  This  factor  is  largely  influenced  by  individual  stability, 
however,  as  a  slight  jar  will  cause  an  abortion  in  one  woman,  and 
violent  experiences  will  have  no  effect  upon  another,  at  the  same  stage 
of  pregnancy. 

Symptoms.  For  purposes  of  differentiation  in  treatment, 
abortions  are  usually  divided  into  three  groups  and  designated 
as  threatened,  complete  and  incomplete,  but  the  premonitory 
symptoms  of  all  of  the  varieties  are  the  same.    They  are  bleeding, 


168  OBSTETRICAL  NURSING 

with  pain  that  is  usually  intermittent,  beginning  in  the  small  of 
the  back  and  finally  felt  as  cramps  in  the  lower  part  of  the  ab- 
domen. Since  menstruation  is  suspended  during  pregnancy,  it 
is  a  safe  precaution  to  regard  any  bleeding  during  this  period, 
with  or  without  pain,  as  a  symptom  of  pending  delivery. 

Prevention  of  abortions  is  of  course  more  satisfactory  than 
remedial  treatment,  and  a  nurse  may  be  very  helpful  in  this  re- 
spect, by  explaining  the  underlying  causes  to  the  patients  in  her 
care,  and  winning  their  cooperation  in  preventing  a  deplorable 
accident. 

Preventive  treatment  really  begins  very  early.  In  the  chap- 
ter on  menstruation  we  referred  to  the  importance  of  a  young 
woman's  ascertaining  the  cause  of  painful  menses,  in  the  inter- 
est of  good  obstetrics,  since  inflammation  of  the  uterine  lining 
or  a  uterine  misplacement  might  be  responsible  not  only  for  the 
dysmenorrhea,  but  if  neglected  might,  later,  be  factors  in  caus- 
ing interrupted  pregnancies.  The  correction  of  such  physical 
defects,  then,  no  matter  when  they  are  discovered,  is  an  im- 
portant step  in  preventing  abortions. 

A  misplacement  may  be  corrected,  frequently,  by  means  of 
a  pessary,  though  suspension  is  done  in  some  cases;  an  inflamed 
lining,  which  provides  unsatisfactory  lodgement  for  the  ovum, 
may  be  removed  by  currettage.  The  new  lining  which  replaces 
the  old  one  is  sometimes  capable  of  receiving  and  holding  the 
ovum. 

There  are  also  some  more  immediate  preventive  measures.  A 
woman  who  is  pregnant  for  the  first  time,  and  who,  therefore, 
does  not  know  whether  or  not  she  is  likely  to  abort,  should  avoid 
such  risks  as  fatigue,  sweeping,  lifting  or  moving  heavy  objects, 
running  a  sewing  machine  by  foot,  running,  jumping,  dancing, 
traveling  or  any  action  which  might  jar  or  jolt  her  during  the 
first  sixteen  or  eighteen  weeks  of  pregnancy. 

On  the  other  hand,  there  are  many  groundless  beliefs  concern- 
ing the  causes  of  abortions  which  the  nurse  may  well  dispel. 
Purgatives  and  other  drugs  have  much  less  effect  in  causing 
abortions  under  normal  conditions  than  is  generally  believed. 
But  with  a  patient  who  has  very  irritable  uterine  muscles,  such 
a  drug  as  quinine,  for  example,  may  act  as  the  last  straw  in  pro- 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  169 

ducing  an  abortion  which  would  almost  certainly  have  been 
brought  on  by  some  other  slight  stimulation  had  the  drug  not 
been  taken.  Nor  can  reaching  up,  or  sleeping  with  the  arms 
over  the  head,  possibly  separate  the  embryo  from  the  uterine 
lining,  yet  manj'  women  believe  that  they  can. 

In  the  case  of  an  expectant  mother  who  has  had  an  abortion, 
even  more  precautions  than  I  have  suggested  will  have  to  be 
taken,  for  she  is  in  greater  danger  of  aborting  than  is  a  woman 
who  has  not  had  this  experience.  It  is  of  prime  importance 
that  she  have  the  cause  of  her  previous  abortion  discovered,  aiid 
if  possible,  corrected.  In  addition  to  this,  she  should  be  par- 
ticularly careful  to  observe  precautionary  measures  as  she  ap- 
proaches the  stage  of  her  pregnancy  at  which  the  previous  abor- 
tion occurred.  The  accident  is  most  likely  to  be  repeated  at 
about  the  same  time,  or  a  little  earlier,  in  each  succeeding  preg- 
nancy. The  patient  should  remain  quietly  in  bed  for  at  least 
a  week  before  and  after  the  time  when  an  abortion  is  feared. 

Complete  rest  and  physical  relaxation  are  such  effective  pre- 
ventive measures  that  patients  with  a  tendency  to  have  abortions, 
who  have  been  willing  to  stay  in  bed  throughout  practically  the 
entire  period  of  gestation,  have  gone  through  pregnancy  without 
interruption,  and  been  delivered  of  normal  babies  at  term.  As 
out-of-door  exercise  is  clearly  impossible  in  such  cases,  it  is  im- 
perative that  the  patient  keep  her  room  particularly  well-ven- 
tilated all  of  the  time,  and,  under  the  doctor's  direction,  have 
massage  or  bed  exercises. 

Since  abortion  seems  to  be  due,  so  often,  to  excessively  irri- 
table uterine  muscle  fibres  that  respond  to  even  slight  stimulation, 
a  patient  who  is  known  to  have  difficulty  in  carrying  a  child  to 
term  is  usually  advised  to  avoid  the  marital  relation  throughout 
pregnancy. 

Some  patients  with  defective  uterine  lining  will  have  slight 
bleeding  for  a  long  time,  possibly  throughout  the  entire  period 
of  pregnancy,  because  a  small  area  of  the  placenta  has  separated, 
leaving,  however,  a  sufficiently  large  attached  area  to  nourish  the 
fetus.  Such  women  should,  of  course,  be  under  a  doctor's  care 
and  sedulously  avoid  all  shocks  to  the  uterine  musculature,  for 
the  separated  area  may  very  easily  be  increased  to  such  a  size 


170  OBSTETRICAL  NURSING 

that  the  fetus  will  be  unable  to  secure  adequate  nourishment, 
and  die  as  a  result.  And  the  mother's  life,  too,  may  be  endan- 
gered by  hemorrhage  from  the  separated  surfaces. 

To  sum  up  in  a  word,  we  may  almost  say  that,  after  preg- 
nancy has  begun,  preventive  treatment  consists  of  rest  and  avoid- 
ing physical  shocks,  particularly  during  the  first  sixteen  or  eight- 
een weeks  and  at  the  time  when  menstruation  would  occur  were 
the  woman  not  pregnant. 

Treatment,  in  the  different  degrees  of  abortion,  employed  by 
most  physicians,  is  usually  along  some  such  lines  as  the  fol- 
lowing : 

1.  Threatened.  A  threatened  abortion  is  one  in  which  there  is 
some  loss  of  blood,  associated  with  pain  in  the  back  and  lower  abdomen, 
but  without  expulsion  of  the  products  of  conception.  The  treatment, 
as  a  rule,  is  absolute  rest  in  bed  and  the  administration  of  powerful 
sedatives. 

2.  Incomplete.  An  incomplete  abortion  is  one  in  which  the  fetus 
is  expelled  but  the  placenta  and  membranes  remain  in  the  uterine  cavity. 
The  treatment  is  removal  of  the  retained  tissues,  followed  by  the  same 
care  that  is  given  during  the  normal  puerperium.  Prompt  action  in 
completing  the  delivery  is  important  because  of  the  hemorrhage  that 
usually  persists  until  the  uterus  is  entirely  emptied  of  its  contents. 
Since  the  pregnant  uterus  is  very  soft,  the  retained  membranes  are 
more  often  removed  manually  than  instnmientallj',  for  a  curette  may 
be  very  easily  pushed  through  the  uterine  wall,  and  peritonitis  would 
be  likely  to  follow. 

3.  Complete.  A  complete  abortion,  as  the  term  suggests,  is  one 
in  which  all  the  products  of  coneei:)tion  are  expelled.  The  treatment  and 
care  are  exactly  the  same  as  are  given  after  a  nonnal  delivery.  This 
point  cannot  be  stressed  too  strongly,  for  it  is  because  so  many  women 
fail  to  appreciate  the  necessity  for  adequate  post-partum  care,  that 
abortions  are  so  often  followed  by  ill  health  and  invalidism. 

Mam'  doctors  follow  these  various  remedial  measures  with  a 
search  for  the  cause  of  the  abortion  just  past,  in  order  that  it 
may  be  corrected  if  possible  and  recurrent  abortions  prevented. 

A  missed  abortion  occurs  but  rarely,  and  is  one  in  which  the 
embryo,  or  fetus  dies,  and  is  retained  within  the  uterine  cavity 
for  months,  or  even  years,  sometimes  without  any  unfavorable 
results  to  the  mother.  In  these  eases,  symptoms  of  abortion  some- 
times appear  and  then  subside  without  any  part  of  the  uterine 


COMPLICATIONS  AND  ACCIDENTS  OP  PREGNANCY  171 

contents  being  expelled.  In  other  eases  there  are  no  signs  ex- 
cept that  the  abdomen  stops  growing.  There  are  cases  on  record 
in  which  the  fetus  has  become  mummified  and  others  in  which 
it  has  been  partly  absorbed  by  the  maternal  organism. 

In  addition  to  abortions  which  occur  spontaneously  there  are 
also  induced  abortions,  and  these  are  designated  as  therapeutic 
or  criminal,  according  to  the  motive  for  the  induction. 

Therapeutic  abortions  are  resorted  to  when  the  i)atient's 
condition  is  so  grave  that  it  is  apparently  necessary  to  empty 
the  uterus  in  order  to  save  licr  life  Sucli  a  condition  may  exist, 
for  example,  when  pregnancy  is  i'om})lic'ated  by  pulmonary 
tuberculosis,  heart  disease,  toxemia,  hemorrhage  or  some  condi- 
tion which  is  inherent  to  pregnancy.  An  abortion  induced  under 
these  circumstances  is  countenanced  by  law,  as  it  is  performed 
to  prevent  the  loss  of  life  from  disease ;  but  an  abortion  is  not 
legal  if  brought  on  to  save  the  woman  from  suicide,  because  of 
her  unwillingness  to  become  a  mother. 

The  Catholic  Church,  however,  teaches  that  it  is  never  per- 
missible to  take  the  life  of  the  child  in  order  to  save  the  life  of 
the  mother.  It  teaches  that,  even  according  to  natural  law,  the 
child  is  not  an  unjust  aggressor :  and  that  both  child  and  mother 
have  an  equal  right  to  life. 

There  is  apparently  no  reason  why  a  therapeutic  abortion 
should  be  followed  by  ill  health,  for,  since  it  is  performed  openly, 
it  is  done  under  clean,  and  otherwise  favorable  conditions,  and 
the  patient  is  given  adequate  after-care.  It  is  only  because  the 
reverse  conditions  frequently  prevail :  the  unclean  delivery  and 
subsequent  neglect  which  go  hand  in  hand  with  the  secrecy  of 
illegal  performance  that  abortions  are  followed  so  often  by 
disaster. 

As  to  the  legal  aspect  of  the  matter,  the  laws  relating  to 
therapeutic  abortion  vary  in  the  different  states.  But  they  are 
fairly  uniform  in  their  intent,  and  make  quite  clear  the  differ- 
ence between  this  procedure  and  the  induction  of  abortion  for 
any  reason  other  than  medical  necessity. 

Dr.  Slemons  writes  of  the  seriousness  of  criminal  abortion 
in  no  uncertain  terms,  in  "The  Prospective  Mother."  "At  Com- 
mon Law"  (an  inheritance  from  England)  he  tells  us,  "abor- 


172  OBSTETRICAL  NURSING 

tion  is  punishable  as  homicide  when  the  woman  dies  or  when  the 
operation  res  alts  fatally  to  the  infant,  after  it  has  been  born 
alive.  If  performed  for  the  purpose  of  killing  the  child,  the 
crime  is  murder;  in  the  absence  of  such  intent,  it  is  manslaughter. 
The  woman  who  commits  an  abortion  upon  herself  is  likewise 
guilty  of  the  crime." 

Premature  Labor  is  the  termination  of  pregnancy  after 
the  seventh  mouth,  but  before  term.  Premature  births  are  much 
less  frequent  than  abortions  or  miscarriages.  They  usually  occur 
spontaneously,  but  are  sometimes  induced  for  therapeutic  pur- 
poses, or  from  criminal  motives. 

The  premature  baby's  chances  of  living  are  directly  propor- 
tionate to  the  length  of  its  uterine  life.  This  has  already  been 
stated,  but  will  bear  repetition  in  view  of  the  widely  current 
fallacy  that  a  seven-months'  baby  is  more  likely  to  live  than  one 
born  after  eight  months  of  pregnancy.  The  facts  are  that  as 
a  rule,  the  nearer  pregnancy  approaches  term,  the  more  likely  is 
the  baby  to  survive,  provided  it  weighs  four  pounds  or  more, 
and  is  forty  centimeters  or  more  in  length.  A  smaller  baby  than 
this  has  but  a  slender  chance  to  live.  * 

We  ordinarily  designate  as  premature  any  baby  that  weighs 
between  1500  and  2500  grams,  or  measures  between  thirty-six 
and  forty-five  centimeters  in  length,  and  consider  such  a  baby 
has  a  favorable  outlook  if  given  special  care.  This  special  care  of 
premature  babies  will  be  described  in  connection  with  the  care  of 
the  baby. 

Causes.  Syphilis  was  formerly  thought  to  be  a  common 
cause  of  abortion,  but  although  this  has  been  disproved  by  recent 
investigations,  the  disease  is  still  regarded  as  a  frequent  cause 
of  spontaneous  premature  labor.  In  fact,  Dr.  Williams  con- 
siders syphilis  the  most  frequent  single  cause  of  premature 
births,  and  regards  the  birth  of  a  dead,  macerated  fetus,  or  a 
history  of  repeated  premature  labors,  or  stillbirths,  as  strongly 
suggestive  of  syphilis. 

"In  my  experience,"  he  says,  "the  recognition  and  treatment 
of  this  disease  is  the  most  important  matter  in  connection  with 
the  prophylaxis  of  premature  labor.  .  .  .  Some  idea  of  the  im- 
portance may  be  gained  from  the  fact  that  in  a  series  of  334  pre« 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  173 

mature  labors,  I  found  that  syphilis  was  the  etiological  factor 
in  over  40  per  cent.,  while  toxemia,  placenta  pnevia  and  fetal 
deformity  were  concerned  in  8.()  and  3.3  per  cent.,  respectively. 
Sentex,  who  studied  485  eases  in  Pinard's  clinic  arrived  at  simi- 
lar conclusions  and  found  the  underlying  cause  to  be  sypliilis  in 
42.7  per  cent.,  albuminuria  in  10.8  per  cent.,  and  abnormalities 
of  the  fetus  in  11.1  per  cent."  ^ 

Other  causes  of  premature  births  are  the  toxemias  of  preg- 
nancy, chronic  nephritis,  diabetes,  pneumonia,  typhoid  fever,  oi-- 
ganic  heart  disease,  continuous  overwork  during  tiie  latter  part 
of  pregnancy,  and  such  poisoning  as  lead  and  illuminating  gas, 
while  of  alcoholism,  Dr.  Ballantyne  says,  "prematurity  of  birth 
is  an  undoubted  result." 

Another  important  cause  of  premature  births,  of  compara- 
tively recent  recognition,  is  previous  operation  upon  the  cervix, 
particularly  high  amputations;  Avhile  placenta  praevia  and  mal- 
formations of  the  fetus,  or  monsters,  are  also  reckoned  with  as 
causative  factors.  Hydramnios  sometimes  brings  on  a  premature 
labor  by  so  distending  the  uterus  as  to  stimulate  contractions. 

Labor  is  sometimes  induced  prematurely  when  this  procedure 
may  be  expected  to  relieve  an  abnormality  or  complication  which 
threatens  the  life  of  the  mother  or  baby,  or  both.  Some  of  the 
indications  for  this  course  are :  seriously  overtaxed  heart  or  kid- 
neys; a  marked  disproportion  between  the  size  of  the  child's 
head  and  the  mother 's  pelvis,  or  a  fetus  that  has  been  dead  for 
two  weeks  or  more.  However,  the  reasons  for  it  and  the  methods 
employed  in  inducing  labor  will  be  discussed  more  at  length 
in  the  chapter  on  obstetric  operations. 

A  therapeutic  induction  of  premature  labor,  like  a  thera- 
peutic abortion,  is  not  of  itself  usually  considered  any  more  seri- 
ous for  the  mother  than  a  normal  delivery,  since  it  can  be  per- 
formed with  care  and  cleanliness,  qualities  not  usually  associated 
with  the  work  of  practitioners  who  are  willing  to  do  criminal 
operations. 

Treatment.  The  nursing  care  of  the  patient  after  a  prema 
ture  labor  is  the  same  as  that  given  after  a  normal  delivery. 
Much  invalidism  would  be  avoided  if  all  women  could  be  con- 

^  "  Obstetrics, "  by  J.  Whitridge  Williams. 


174 


OBSTETRICAL  NURSING 


vinced  of  the  importance  of  staying  in  bed  just  as  long,  and  hav- 
ing just  as  good  care  after  a  premature  as  after  a  full-term 
labor.  The  difficulty  of  so  convincing  her  is  perhaps  due  to  the 
fact  that  the  small,  premature  child  is  expelled  more  quickly  and 
less  painfully  than  a  baby  at  term  and  there  is  comparatively 
little  blood  lost  in  the  course  of  its  birth. 


ANTE-PARTUM  HEMORRHAGE 

Ante-partum  hemorrhage,  which  is  a  hemorrhage  occur- 
ring before  delivery,  is  another  serious  complication  of  preg- 
nancy. During  the  early  months,  hemorrhages  are  usually  due 
to  abortion,  menstruation  or  lesions  of  the  cervix  and  are  not 

severe  as  a  rule.  But  during  the  last 
three  months  hemorrhages  are  almost 
invariably  due  to  placenta  praevia  or 
premature  separation  of  a  normally 
implanted  placenta,  and  are  often  pro- 
fuse. 

Placenta  Prx3cvia  is  one  of  the 
most  serious  conditions  met  with  in 
obstetrics,  the  maternal  mortality 
being  about  40  per  cent,  and  the  baby 
death  rate  about  66  per  cent.  The 
frequency  with  wiiich  it  occurs  is 
variously  estimated  as  from  one  in 
250  cases  to  one  in  every  1000. 

In  order  to  understand  w'hat 
is  happening  to  the  patient  in  this 
condition,  we  must  go  back  to  the 
question  of  the  implantation  of 
the  ovum.  We  learned  that,  as  a 
rule,  after  the  ovum  entered  the  uterus  it  attached  itself 
to  a  point  in  the  uterine  lining  high  up  on  the  anterior  or 
posterior  wall.  Unhappily,  the  position  of  this  point  of  at- 
tachment is  a  mere  matter  of  chance,  and  the  ovum  some- 
times, but  not  often,  is  implanted  so  far  down  toward  the 
cervix  that  as  the  placenta  develops  at  that  site  it  partially 


Fig.  44. — Diagram  of 
centrally  implanted  placenta 
praevia. 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  175 


Pig.  45.— Partial  placenta  praevia.  Section  of  uterine  wall  and  cervix 
showing  that  part  of  the  maternal  surface  of  the  placenta  which  extends 
over  the  cervical  opening  and  is  exposed  by  dilation  of  the  internal  os, 
with  an  escape  of  blood  from  the  open  vessels  as  a  result.  Drawn  by  Max 
Brodel.  (From  "The  Treatment  of  Placenta  Praevia,"  by  William  B. 
Thompson,  M.D.— Johns  Hopkins  Hospital  Bulletin,  July,  1921.) 


176 


OBSTETRICAL  NURSING 


or  completely  overlaps  the  internal  os.  It  is  the  extent  to 
which  the  placenta  grows  over  the  cervical  opening  that 
determines  whether  it  is  of  the  central,  partial  or  marginal 
variety. 

A  centrally  implanted  placenta  prcevia  (Fig.  44)  is  one  which 
entirely  covers  the  os;  a  partial  placenta  prcevia  (Fig.  45),  as 
the  name  suggests,  only  partially  covers  the  opening,  while  if 
it  is  implanted  so  high  up  that  only  its  margin  overlaps  the  os, 
it  is  designated  as  marginal  placenta  prcevia.     (Fig.  46.) 

Another  classification  groups  all  placenta  previa  as  complete 
or  incomplete,  the  latter  comprising  the  partial  and  marginal 

varieties,  as  well  as  the  lateral  which 
is  so  attached  that  it  does  not  quite 
reach  the  edge  of  the  internal  os. 
However,  as  these  terms  do  not  differ 
widely  and  are  clearly  descriptive,  the 
differences  are  of  no  great  moment  to 
the  nurse,  as  the  treatment  is  prac- 
tically the  same  and  the  nurse 's  duties 
quite  the  same  for  all  varieties. 

Cause.  Not  much  is  definitely 
known  about  the  cause  of  placenta 
praevia,  but  it  is  evident  that  multi- 
parity  is  a  factor,  since  the  condition 
is  found  about  six  times  as  frequently 
among  women  who  have  borne  chil- 
dren, as  it  is  among  those  who  are 
pregnant  for  the  first  time.  A  diseased 
uterine  lining  is  probably  the  fundamental  cause,  and  this  may 
explain  why  the  trouble  is  found  more  frequently  among  the 
poorer  classes,  since  such  women  as  a  class  have  less  skilled 
medical  attention  than  those  in  better  circumstance. 

One  theory  is  that  an  old  endometritis  results  in  a  very  un- 
fertile soil  for  the  implantation  of  the  ovum  and  as  a  result 
the  ovum  migrates  to  other  parts  of  the  uterine  cavity  in  its 
search  for  a  more  favorable  site,  and  comes  to  lodge  near  the 
lower  segment. 

Symptoms.     The   symptom   of  placenta   prsevia    is   hemor- 


FiG.  46. — Diagram  of  mar- 
ginal placenta  prsevia. 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  177 

rhage,  occurring  during  the  latter  part  of  pregnancy  or  at  the 
onset  of  labor.  The  cause  of  the  hemorrhage  is  the  separation 
of  that  part  of  the  placenta  covering  the  internal  os,  when  the 
latter  dilates,  thus  presenting  an  exposed,  bleeding  surface.  The 
hemorrhage  is  usually  so  profuse  that  uidess  it  is  controlled, 
both  niotlier  and  child  may  bleed  to  deatli. 

Treatment.  Unhappily  there  is  no  preventive  treatment  for 
placenta  pra3via,  beyond  that  which  is  included  in  treatment  for 
endometritis,  and  good  care  during  the  preceding  puerperium. 


Fig.  47. — Position  of  Champetier  de  Ribes'  bag  to  stop  hemorrhage,  from 
placenta  praevia,  by  pressure. 


Since  the  great  danger  in  this  complication  is  from  hemor- 
rhage the  doctor's  principal  effort  is  directed  toward  its  control. 
Infection  and  shock  are  also  feared  but  the  first  step  is  to  stop 
the  bleeding.  A  common  method  is  to  stimulate  the  uterus  to 
contract ;  that  necessitates  the  removal  of  its  contents,  or  the 
induction  of  labor. 

The  separation  of  the  placenta  leaves  open,  bleeding  vessels 
in  the  uterine  wall  and  placenta,  which  can  only  be  closed  by 
pressure,  until  the  uterus  contracts  on  its  own  vessels.  The  doc- 
tor sometimes  makes  pressure  with  tampons  of  gauze,  by  ruptur- 
ing the  membranes  and  bringing  down  tlie  i^resenting  part  of  the 
child  to  press  against  the  bleeding  surface,  or  by  introducing  a 


178  OBSTETRICAL  NURSING 

rubber  bag  into  the  cervix  and  pumping  it  full  of  sterile  water. 
(Fig.  47.)  By  means  of  its  weight  and  downward  traction,  this 
bag  presses  against  the  bleeding  areas  and  thus  checks  the 
hemorrhage.  It  also  tends  to  dilate  the  cervix,  after  which  the 
baby  is  sometimes  born  spontaneously  and  sometimes  delivered 
artificially. 

Premature  Separation  of  a  Normally  Implanted  Pla- 
centa. A  placenta  praevia,  as  has  been  explained,  is  abnormally 
situated.  But  it  sometimes  happens  that  a  pla(^enta  that  is 
normally  placed  will  separate  prematurely,  Avith  hemorrhage  as 
the  inevitable  result.  Such  a  hemorrhage  is  termed  "acci- 
dental" to  distinguish  it  from  the  unavoidable  bleeding  caused 
by  a  placenta  prsevia.  If  the  blood  escapes  from  the  vagina, 
the  hemorrhage  is  called  "frank,"  but  if  it  is  retained  within 
the  uterine  cavity  it  is  called  a  "concealed"  hemorrhage. 

Causes.  Endometritis  is  probably  an  underlying  cause, 
though  very  little  is  definitely  known  on  the  subject.  Previous 
pregnancies  are  believed  to  be  a  factor,  as  this  accident  occurs 
less  often  among  women  who  are  pregnant  for  the  first  time 
than  among  those  who  have  borne  children,  and  also  as  the  fre- 
quency of  the  hemorrhages  apparently  increases  with  the  number 
of  previous  pregnancies.  Nephritis  is  believed  to  be  a  possible 
cause,  as  well  as  anemia,  general  ill-health,  toxemia,  physical 
shocks,  and  frequently  recurring  pregnancies. 

Symptoms.  In  a  frank  hemorrhage,  the  chief  symptom 
is  an  escape  of  blood  from  the  vagina,  occasionally  accompanied 
by  pain.  A  frank  accidental  hemorrhage  occurs  once  in  about 
every  two  hundred  cases,  according  to  Dr.  Edgar's  estimate,  but, 
although  more  frequent  than  placenta  praevia,  it  is  much  less 
serious. 

A  concealed  accidental  hemorrhage,  on  the  other  hand,  is 
an  extremely  grave  complication  for  both  mother  and  child, 
for  according  to  observations  made  by  Dr.  Goodell,  the  death 
rate  is  51  per  cent,  among  mothers  and  94  per  cent,  among 
babies.^  The  symptoms  are  acute  anemia,  abdominal  pain,  a 
general  state  of  shock,  and  usually  an  increased  enlargement  of 
the  uterus.    The  blood  may  be  retained  between  the  uterine  wall 

^ ' '  The  Practice  of  Obstetrics, "  by  J.  Clifton  Edgar. 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  179 

and  the  placenta  or  membranes,  or  its  escape  from  the  vagina 
may  be  prevented  by  the  child's  presenting  part  fitting  tightly 
into  the  outlet  and  acting  as  a  plug. 

Treatment.  The  treatment  of  a  frank  hemorrhage  depends 
upon  its  severity.  If  the  bleeding  is  only  moderate,  labor  is 
ordinarily  allowed  to  proceed  normally  and  unassisted.  If  the 
bleeding  is  profuse,  however,  the  patient  is  usually  delivered 
promptly. 

The  treatment  for  a  concealed  hemorrhage  consists  of  empty- 
ing the  uterus  speedily  in  order  that  tlie  muscles  may  contract 
and  stop  the  bleeding  by  closing  the  uterine  vessels;  and  of 
treating  the  accompanying  shock  which  may  be  almost,  if  not 
quite,  as  serious  as  the  hemorrhage  itself. 

It  is  very  disappointing  to  have  to  realize  that  there  is  very 
little  that  a  nurse  may  do,  before  the  arrival  of  the  doctor,  for 
a  patient  who  is  having  an  ante-partura  hemorrhage.  As  has 
been  explained,  it  is  often  necessary  to  pack  the  cervix  or  intro- 
duce a  bag,  for  the  purpose  of  stopping  the  bleeding  by  pressure, 
and  of  stimulating  the  uterine  contractions  which  will  expel  the 
child  and  empty  the  uterus.  These  measures  are  surgical  opera- 
tions and  quite  evidently  the  nurse  cannot  attempt  to  perform 
them.  She  can,  however,  put  the  patient  to  bed  and  have  her 
lie  flat,  without  a  pillow,  and,  partly  for  the  mental  effect  upon 
the  patient,  apply  ice-bags  or  compresses  to  her  abdomen.  As 
nervousness  and  excitement  only  tend  to  increase  the  bleeding, 
the  nurse  has  an  excellent  opportunity  to  try  to  soothe  and  quiet 
a  frightened  Avoman,  and  convince  her  that  she  can  help  herself, 
in  this  emergency,  by  quieting  her  mind  and  body. 

Pending  the  doctor's  arrival,  the  nurse  should  have  a  large 
receptacle  of  water,  boiling,  to  sterilize  the  instruments  and 
bags  that  he  may  want  to  use;  clean  towels  and  sheets,  a  nail 
brush,  hot  Avater,  soap,  and  a  basin  of  an  antiseptic  solution 
for  his  hands. 

TOXEMIAS   OF   PREGNANCY 

There  is  probably  no  group  of  complications  which  prove 
to  be  more  baffling  to  the  obstetrician  than  the  toxemias  of  preg- 


180  OBSTETRICAL  NURSING 

nancy.  Certainly  they  are  challenging  the  best  efforts  of  many 
earnest  investigators,  for  it  is  known  that  the  toxemias  cause 
some  of  the  gravest  conditions  that  arise  during  pregnancy,  and 
they  are  suspected  of  being  the  underlying  cause  of  still  others 
which  are  as  yet  unaccounted  for. 

Comparatively  little  is  known  of  the  origin  of  the  toxemias, 
except  that  they  are  due  to  pregnancy.  But  happily,  a  good 
deal  is  known  about  preventing  them,  and  also  about  relieving 
them,  particularly  in  the  early  stages ;  accordingly  many  mothers 
and  babies  are  saved  who  otherwise  would  perish. 

The  entire  subject  of  the  prevention  and  treatment  of  these 
disorders  will  be  somewhat  simplified  for  the  nurse  if  she  will 
recall  the  general  question  of  the  adaptations  of  the  mother's 
physiologj^  during  pregnancy.  She  will  then  remember  that 
there  were  certain  alterations  of  function  which  were  necessary 
to  keep  the  maternal  organism  normal,  while  it  bore  the  strain 
of  supplying  nourishment  to  the  fetus  from  its  own  blood  stream, 
and  received  in  turn  the  broken-down  products  of  fetal  activity. 
If  these  adaptations  are  insufficient  to  meet  the  demands  made 
upon  the  maternal  organism,  a  serious  toxic  condition  may 
result. 

To  put  the  matter  briefly,  there  is  in  the  toxemias  of  preg- 
nancy a  disturbance  of  the  mother's  metabolism,  involving  the 
liver  and  kidneys,  and  a  resulting  retention  within  her  body  of 
something  which  should  be  excreted.  The  retention  of  this  ma- 
terial, which  may  be  of  fetal  or  maternal  origin,  or  both,  may 
give  rise  to  symptoms  which  range  anywhere  from  slight  head- 
ache or  nausea  to  coma,  convulsions  and  death. 

Beyond  these  general  facts,  there  seems  to  be  deep  obscurity 
concerning  the  cause  of  this  group  of  complications,  of  which 
pernicious  vomiting,  pre-eclamptic  toxemia  and  eclampsia  are 
the  most  widely  and  generally  recognized. 

While  nephritic  toxemia  and  acute  yellow  atrophy  of  the  liver 
cannot  be  designated,  quite  accurately,  as  toxemias  due  to  preg- 
nancy, they  are  usually  included  in  this  group.  This  may  be 
because  they  are  toxemias  which  have  many  features  in  common 
with  those  of  pregnancy,  as  to  symptoms  and  treatment,  and 


COMPLICATIONS  AND  ACCIDENTS  OP  PREGNANCY  181 

because  of  the  frequency  with  which  they  appear  coincidently 
with  pregnancy,  although  not  always  due  primarily  to  that 
state. 

From  the  nurse's  standpoint,  it  will  perhaps  be  as  well  to 
regard  all  of  the  toxemias  of  pregnancy  as  manifestations  of 
the  same  general  disturbance,  which  vary  according  to  the  stage 
of  pregnancy  at  which  they  appear,  and  which  differ  from  each 
other  chiefly  in  severity,  or  degree,  rather  than  in  kind. 

In  all  cases  the  patients  need  to  have  their  toxicity  lessened 
by  dilution,  and  this  is  accomplished  by  giving  fluids,  copiously, 
and  by  increasing  elimination  by  promoting  the  activity  of  the 
skin,  kidneys  and  bowels.  And  since  the  nervous  system  is  irri- 
tated by  the  toxins,  sometimes  slightly  and  sometimes  pro- 
foundly, the  patient  must  be  protected  from  outside  irritation 
and  stimulation.  This  means  quiet ;  a  soft  light,  or  even  dark- 
ness in  the  room;  gentle  handling;  and  with  mildly  toxic,  con- 
scious patients,  a  pleasant,  reassuring  and  encouraging  man- 
ner. With  those  who  are  unconscious,  each  touch  must  be  the 
lightest  and  gentlest  possible. 

These  are  the  main  features  of  the  nursing  care:  forcing 
fluids  and  keeping  the  patient  warm  and  quiet.  They  offer 
the  nurse  wide  scope  in  adjustment  and  adaptation  to  each 
patient,  according  to  her  immediate  condition  and  to  the  methods 
of  the  physician  in  charge.  There  is  a  difference  of  opinion 
among  doctors  as  to  details  of  treatment,  but  the  fundamentals 
of  the  care  are  the  same.  In  taking  up,  in  turn,  these  mani- 
festations of  disturbed  metabolism  during  pregnancy,  we  find 
that  vomiting  is  the  first  to  appear. 

Pernicious  Vomiting  of  Pregnancy  usually  occurs  during 
the  first  three  months.  We  learned  in  the  preceding  chapter  that 
a  milder  form  of  the  malady,  known  as  "morning  sickness,"  is 
present  in  about  half  of  all  pregnancies.  This  mild  type  ordi- 
narily consists  of  a  feeling  of  nausea,  possibly  accompanied  by 
vomiting,  immediately  upon  raising  the  head  in  the  morning, 
and  a  capricious  appetite.  It  appears  at  about  the  fourth  or 
sixth  week  and  subsides  in  the  course  of  a  few  weeks,  sometimes 
after  no  more  care  than  the  nursing  which  was  described,  leaving 
the  patient  none  the  worse  as  a  result  of  the  attack. 


182  OBSTETRICAL  NURSING 

With  some  women,  however,  the  distress  does  not  disappear 
in  this  prompt  and  satisfactory  manner,  in  which  case  it  is 
described  as  ''pernicious  vomiting."  The  nausea  in  the  morn- 
ing may  then  persist  for  hours;  it  may  occur  later  in  the  day, 
or  even  at  night;  it  may  come  on  during  a  meal  and  consist  of 
a  single  attack  of  vomiting,  after  which  food  is  taken  and  re- 
tained ;  or  it  may  be  so  persistent  that  the  patient  will  be  unable 
to  retain  anything  taken  by  mouth  at  any  time  of  the  day  or 
night.  Such  a  condition,  is,  of  course,  serious,  and  may  termi- 
nate fatally.  The  patient  may  become  exhausted  from  lack  of 
food  or  because  of  the  toxic  condition  which  is  responsible  for 
the  vomiting,  or  both. 

There  seem  to  be  three  possible  classifications  of  pernicious 
vomiting:  (1)  One  of  reflex  origin,  (2)  one  of  neurotic  origin, 
and  (3)  one  due  to  a  toxemia,  resulting  from  disturbed  meta- 
bolism. Not  all  physicians  accept  the  possibility  of  all  of  these 
factors,  however,  for  while  some  recognize  both  toxemia  and 
neuroses  as  causes,  they  question  the  possibility  of  a  reflex  cause. 
Others  believe  that  all  nausea  of  pregnancy,  from  the  mildest 
to  the  most  severe  form,  is  of  toxic  origin,  while  still  others  con- 
tend that  even  the  severest  pernicious  vomiting  is  always  neu- 
rotic. However,  as  toxicity  under  any  conditions  is  very  likely 
to  give  rise  to  nervous  symptoms,  and  as  a  nervous,  unstable 
woman  may  be  made  very  ill  by  a  slight  degree  of  toxicity,  it 
may  be  that  both  factors  sometimes  enter  into  the  causation  of 
this  disorder. 

Reflex  vomiting-.  Those  who  subscribe  to  the  theory  of 
reflex  vomiting  believe  that  it  may  result  from  the  irritation 
caused  by  a  retroverted  uterus,  or  occasionally  by  an  ovarian 
cyst,  an  erosion  on  the  cervix  or  by  adhesions. 

The  treatment  for  reflex  vomiting,  quite  obviously,  consists 
of  correcting  the  disturbing  condition,  whatever  it  may  be,  after 
which  the  nausea  usually  subsides  in  a  short  time.  The  nurse 
should  take  care  that  her  patient  resumes  a  regular  diet 
very  gradually,  even  after  the  cause  of  the  nausea  has  been 
removed,  for  the  stomach  has  become  irritable  and  the  vomiting 
habit,  both  mental  and  physical,  though  easily  established,  is 
usually  broken  up  with  considerable  difficultv.     Breakfast  in 


COMPLICATIONS  AND  ACCIDENTS  OP  PREGNANCY  183 

bed;  concentrated  liquid  foods  or  easily  digested  solids,  particu- 
larly carbohydrates;  aerated  Avaters;  cold  fruit  juices  and 
cracked  ice  are  easy  to  retain  and  tend  to  allay  nausea. 

Neurotic  vomiting.  Severe  vomitiii<i'  Avliidi  is  due  to 
some  kind  of  mental  stress  or  suffering-,  and  connnonly  called 
"neurotic  vomiting,"  is  not  always  so  easily  relieved.  In  the 
opinion  of  many  psychiatrists  the  vomiting  frequently  consti- 
tutes a  protection,  or  possibly  a  protest,  which  the  patient  has 
developed  subconsciously,  because  of  some  reason  for  fearing, 
or  not  wanting,  to  become  a  mother. 

It  is  difficult  to  outline  the  nursing  care  of  such  patients 
with  any  degree  of  precision,  as  no  two  can  be  cared  for  in 
quite  the  same  way.  While  in  some  cases  the  patient  is  a  selfish, 
overindulged  woman  who  objects  to  motherhood  because  of  its 
inconveniences,  in  others,  she  is  tortured  by  fear  of  inability  to 
go  through  her  pregnancy  successfully,  though  sincerely  want- 
ing to ;  or  she  may  be  bewildered  and  overwhelmed  by  the  pros- 
pect of  the  dangers  of  childl)irth  and  responsibilities  of  mother- 
hood, a  truly  pathetic  figure  whose  distress  may  often  be  greatly 
relieved  by  the  nurse  who  has  enough  insight  to  grasp  the  situa- 
tion. As  I  have  discussed  this  subject  more  at  length  in  the 
chapter  on  mental  hygiene,  I  shall  say  only  a  word  here,  as  a 
reminder  that  the  nurse  will  need  all  of  the  tact,  resourceful- 
ness, sympathy  and  understanding  which  she  is  capable  of  offer- 
ing, if  she  is  to  give  real  help  to  some  of  her  patients  who  suffer 
from  neurotic  vomiting. 

In  addition  to  the  mental  nursing,  which  will  be  necessary, 
the  patient  also  needs  physical  care,  for  though  her  trouble  may 
be  of  emotional  origin,  she  is,  nevertheless,  physically  ill.  As 
a  rule,  the  best  results  are  obtained  by  putting  the  patient  to 
bed  and  separating  her  from  her  family  as  completely  as  possible. 
A  daily  routine  should  be  adopted  and  rigidly  observed,  and 
the  patient  repeatedly  assured  that  the  course  being  followed 
will  end  in  recovery. 

It  is  usually  considered  advisable  not  to  offer  food  by  mouth, 
in  the  beginning,  but  instead  to  give  nourishment,  as  well  as 
large  amounis  of  saline  and  sugar  solutions  by  enemata,  during 
tlie  first  few  days.     One  routine  is  to  give  500  cubic  centimetres 


184  OBSTETRICAL  NURSING 

v&ry  slowly,  every  six  hours  at  first,  gradually  decreasing  the 
treatments  to  one  a  day  as  the  patient  improves.  The  rectum  is 
irrigated  with  a  simple  enema,  once  daily,  immediately  preced- 
ing one  of  the  injections,  consisting  of  an  ounce  of  dextrose  or 
glucose  and  one  dram  of  salt  to  a  pint  of  water. 

Small  amounts  of  liquid  nourishment  are  finally  given  by 
mouth,  and  given  frequently,  the  quantity  being  increased  grad- 
ually as  the  patient  improves.  Very  light  and  easily  digestible 
solid  foods,  chiefly  carbohydrates,  are  added  by  degrees,  and 
in  the  end,  five  or  six  small  meals,  rather  than  three  full  ones, 
are  given  in  the  course  of  the  day. 

In  some  cases  the  patient  is  induced  to  drink,  daily,  two  or 
three  quarts  of  sugar  solution  (an  ounce  of  lactose  to  a  pint  of 
water),  and  to  nibble  at  will  on  olives,  walnuts,  crisp  crackers, 
or  some  such  articles  of  food,  which  are  kept  within  reach  on  her 
bedside  table.  These  are  usually  retained,  excepting  in  very 
severe  cases,  to  the  patient's  great  encouragement. 

The  duration  and  severity  of  the  attacks  vary  widely.  Some 
patients  are  very  ill  and  for  a  long  time,  even  requiring  an  abor- 
tion before  showing  signs  of  improvement,  while  others  recoyer 
in  a  few  days  if  wisely  managed.  If  a  patient  once  suffers  from 
neurotic  vomiting,  she  is  very  likely  to  have  it  in  subsequent 
pregnancies,  particularly  if  the  circumstances  of  her  life  remain 
unaltered. 

Toxemic  vomiting  is  regarded  by  some  doctors  as  a  very 
grave  and  very  rare  complication  of  pregnancy,  which  is  usu- 
ally fatal;  by  others  as  simply  a  severe  form  of  the  very  com- 
mon ' '  morning  sickness, ' '  which  they  believe  is  always  toxic,  no 
matter  how  mild ;  while  still  others,  as  already  stated,  doubt  the 
occurrence  of  such  a  condition  as  toxemic  vomiting  of  preg- 
nancy. I  mention  these  differences  of  opinion  in  order  that 
the  nurse  may  be  aware  of  their  existence  and  be  prepared  to 
adjust  herself  whole-heartedly  to  the  different  methods  of  treat- 
ment for  which  they  are  responsible.  For  no  matter  what  else 
may  vary,  the  earnestness  and  sincerity  of  the  nurse's  attitude 
must  be  a  veritable  Gibralter  of  reliability. 

The  chief  symptoms  of  toxemic  vomiting,  in  addition  to 
persistent  vomiting,   as  described  by   those   who   recognize   its 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  185 

occurrence,  are  coffee-ground  vomitus;  a  diminished  amount  of 
urine,  possibly  containing  albumen,  acetone  bodies  and  casts; 
coma  and  sometimes  convulsions.  The  disease  may  run  its  course 
swiftly  and  the  patient  die  in  a  week  or  ten  days,  or  it  may 
persist  less  acutely  for  weeks,  in  which  case  there  is  extreme 
emaciation  and  prostration.  In  those  cases  Avhich  come  to 
autopsy  there  is  a  definite  and  characteristic,  central  necrosis 
of  the  liver  lobule. 

The  treatment  and  nursing  care  vary  widely  because  so 
little  is  definitely  known  about  the  cause,  and  because  of  the 
varieties  of  theories  concerning  it  which  are  held  by  different 
obstetricians.  Some  believe  that  prompt  emptying  of  the  uterus 
is  about  the  only  course  which  is  effective,  whilo  others  foel  that 
because  of  the  probable  toxicity  of  the  patient  it  is  advisable  also 
to  stimulate  all  of  the  excretory  organs.  Accordingly,  they  give 
free  purges,  colonic  irrigations,  hot  packs  and  copious  amounts 
of  sugar  and  saline  solution  by  mouth,  rectum,  intravenously  and 
by  infusion. 

Corpus  luteum,  too,  is  sometimes  given  hypodermically  two 
or  three  times  weekly.  Although  this  treatment  is  not  in  uni- 
versal use  or  favor,  some  patients  seem  to  be  given  absolute  relief 
by  its  administration. 

A  fairly  typical  method  of  treating  toxemic  vomiting,  and 
of  which  the  nursing  care  forms  a  large  part  is  somewhat  as 
follows:  When  the  vomiting  is  only  moderately  severe,  the 
patient  is  put  to  bed  and  isolated  from  relatives  and  friends, 
because  of  her  nervousness  resulting  from  the  toxemia.  She 
is  given  an  abundance  of  very  cold,  5  per  cent,  lactose  solution 
by  mouth  in  water  or  lemonade ;  from  four  to  six  ounces  being 
given  every  half  hour  if  she  is  able  to  retain  it.  If  she  is  unable 
to  take,  by  mouth,  a  total  of  about  three  litres  of  this  solution,  in 
the  course  of  twenty-four  hours,  she  is  sometimes  given  one  or 
two  litres  (of  a  10  per  cent,  solution)  by  rectum  by  means  of  the 
drip  method.  At  least  three  hours  are  devoted  to  giving  this 
amount  of  fluid,  the  rectum  being  first  washed  out  with  a  simple 
enema. 

It  is  usually  considered  important  to  persist  in  giving  small 
amouot^  of  practically  any   article   of   food  that   the   patient 


186  OBSTETRICAL  NURSING 

fancies,  in  order  to  encourage  her  in  the  belief  that  she  can 
take  nourishment  and  also  to  accustom  her  stomach  to  receive 
and  retain  food.  Olives  and  nuts  are  particularly  valuable  for 
this  purpose  and  are  often  kept  on  the  patient's  bedside  table 
where  she  can  reach  them  and  nibble  on  them  at  will.  Ice  cold 
fruits  and  fruit  juices  are  useful,  while  strained  apple  sauce,  ice 
cold,  is  very  valuable  as  a  starting  point  from  which  a  more 
generous  diet  may  be  gradually  developed.  All  foods  should  be 
very  cold  except  broths,  which  should  be  very  hot.  The  dietary 
is  gradually  increased  to  six  small  meals  daily  from  which  fats 
and  proteids  are  omitted. 

In  more  severe  cases,  or  if  the  patient  does  not  improve,  an 
injection  of  300  cubic  centimetres  of  fresh  5  per  cent,  solution 
of  glucose  is  given  under  each  breast  daily,  and  sometimes  a 
mild  sweat-bath,  given  with  blankets  and  lasting  twenty  minutes. 
(See  page  197  for  sweat-bath.) 

In  very  severe  cases  when  the  patient  is  unable  to  retain  any- 
thing taken  by  mouth ;  loses  weight  and  strength ;  when  possibly 
the  urine  decreases  in  amount  and  contains  acetone  bodies  and 
ammonia,  the  situation  is  serious  and  the  treatment  is  more 
drastic.  All  effort  to  give  fluid  by  mouth  is  abandoned  and  in 
addition  to  the  sub-mammary  injection  of  glucose  solution,  a 
colonic  irrigation  of  one  and  a  half  to  two  gallons  of  sodium 
bicarbonate  solution  (from  2%  to  5%)  at  110°  F.,  is  given  once 
daily  by  the  drip  method.  The  daily  hot  pack  is  continued;  a 
mustard  leaf  is  applied  to  the  abdomen  if  necessary  to  relieve  the 
pain  and  nausea;  glucose  solution  may  be  given  intravenously 
and  also  a  nutritive  enema,  three  times  daily,  consisting  of  a  raw 
egg,  four  ounces  of  peptonized  milk  and  one-half  ounce  of 
whiskey. 

The  method  employed  at  the  Toronto  General  Hospital  in 
treating  patients  suffering  from  toxemic  vomiting  is  outlined 
as  follows  by  Dr.  J.  G.  Gallic:  "The  patient  is  given  as  much 
as  she  is  able  to  drink.  A  nutrient  enema  is  given  three  or  four 
times  daily,  consisting  of  six  ounces  of  a  10  per  cent,  solution  of 
glucose  in  saline.  Bromide  and  chloral  may  have  to  be  added 
to  the  last  nutrient  in  the  evening.  A  simple  enema  is  given 
each  morning.     Nutrients  are  discontinued  when  the  urine  be- 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  187 

comes  free  of  acetone  bodies.  In  more  severe  cases,  where  fluid 
cannot  be  taken  by  mouth,  it  may  be  supplied  interstitially  or 
intravenously,  a  5  per  cent,  solution  of  glucose  being  used.  When 
vomiting  ceases,  and  solid  food  can  be  taken,  the  feeding  is 
begun  very  carefully  with  small  quantities  of  carbohydrates. 
Lactose  is  added  where  possible  to  any  fluid  taken.  Frequent 
small  meals  are  then  instituted — six  between  7  a.m.  and  10.30 
p.m.j  thus  reducing  to  the  smallest  space  of  time  the  period  of 
starvation  during  the  twenty-four  hours.  Protein  may  be  added 
to  the  diet  wlien  nausea  is  under  control,  but  fat  should  be  left 
out  for  some  time." 

Such  a  course  of  treatment,  quite  evidently,  is  designed  to 
relieve  a  toxic  condition,  in  which  increased  elimination  is  im- 
portant, and  to  quiet  an  irritable  nervous  system. 

As  the  patient  with  toxemic  vomiting  is  often  very  uncom- 
fortable because  of  a  bad  taste  and  dryness  of  her  mouth,  some 
kind  of  a  mouth  wash  which  she  finds  refreshing  should  be  used 
frequently.  And  since  a  degree  of  toxicity  which  is  capable  of 
producing  such  a  condition  as  is  described  above  will  almost 
inevitably  produce  nervous  symptoms,  as  well,  the  nurse's  atti- 
tude toward  her  patient  must  always  be  one  of  sympathy,  en- 
couragement and  optimism. 

When  the  patient's  condition  is  so  desperate  that  pregnancy 
is  terminated,  with  the  hope  of  saving  her  life,  ether  or  nitrous 
oxide  gas,  or  both,  is  used  as  an  anesthetic  rather  than  chloro- 
form, which  of  itself  tends  to  produce  a  liver  necrosis. 

Pre-eclamptic  Toxemia  is  the  most  common  of  all  the  tox- 
emias of  pregnancy,  occurring  several  times  in  every  hundred 
pregnancies.  It  develops  more  frequently  among  women  who 
are  pregnant  for  the  first  time  than  among  those  who  have  borne 
children,  and  one  attack  usually  confers  an  immunity  against  a 
recurrence. 

As  pre-eclamptic  toxemia  usually  responds  to  treatment,  but 
if  neglected,  frequently  ends  in  the  much  more  serious  disease 
of  eclampsia,  the  imperative  need  of  supervision  and  care  during 
pregnancy  are  once  more  borne  in  upon  us. 

Symptoms.  Pre-eclamptic  toxemia  seldom  appears  before 
the  second  half  of  pregnancy,  usually  not  until  after  the  sixth 


188  OBSTETRICAL  NURSING 

or  seventh  month,  and  the  symptoms  vary  widely  in  severity. 
They  may  range  from  headache  and  nausea,  so  slight  as  to  cause 
the  patient  little  or  no  inconvenience,  to  coma  and  death. 

The  patient  may  be  entirely  normal  for  six  or  seven  months 
and  then  notice  that  her  rings  and  shoes  are  a  little  tight,  be- 
cause of  the  slight  swelling  of  her  hands  and  feet.  Puffiness 
of  the  eyelids  may  appear,  and  other  parts  of  the  body  may 
also  be  slightly  swollen.  Headache,  dizziness,  lassitude,  drowsi- 
ness, depression,  apprehension,  nausea  and  vomiting  are  all 
symptoms,  as  also  are  high  blood  pressure  and  a  diminished 
amount  of  urine,  containing  albumen.  The  patient  frequently 
complains  of  visual  disturbance,  which  may  be  only  a  slight 
blurring,  but  in  severe  cases  may  amount  to  total  blindness. 

Other  symptoms,  when  the  condition  is  grave,  are  epigastric 
pain ;  rapid  pulse ;  extreme  nervousness  and  excitement,  which 
may  amount  almost  to  insanity;  or  drowsiness,  which  grows 
deeper  and  deeper  until  the  patient  sinks  into  a  coma.  Under 
such  conditions,  she  may  die  without  recovering  consciousness, 
but  more  frequently,  eclampsia  ensues.  The  child  may  perish 
as  a  result  of  the  toxemia  and  a  dead,  premature  baby  be  born. 

Prevention  is  of  course,  the  most  important  aspect  of  the 
treatment  and  is  accomplished  by  means  of  the  pre-natal  care 
and  supervision  which  were  described  in  the  last  chapter.  In 
this  connection  must  be  mentioned  again  the  danger,  during 
pregnancy,  of  overeating.  It  is  more  and  more  frequently  ob- 
served that  toxemic  seizures  follow  in  the  wake  of  a  single,  large, 
heavy  meal,  such  as  one  is  so  likely  to  take  at  Thanksgiving  or 
Christmas  time.  This  is  particularly  true  of  patients  who  have 
had  nausea  or  wlio  have  even  slightly  disabled  kidneys,  which, 
though  able  to  meet  the  ordinary  demands  made  by  pregnancy, 
are  inadequate  to  cope  with  the  sudden  strain  imposed  by  a  large 
meal.  In  such  a  case,  toxic  materials  which  should  be  excreted 
are  retained  within  the  body,  and  the  familiar  symptoms  of 
toxemia  are  the  result. 

Much  the  same  condition  is  produced  by  the  patient 's  getting 
wet  or  chilled.  The  excretory  function  of  the  skin  is  interfered 
with,  under  such  circumstances,  and  the  kidneys  are  unable  to 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  189 

do  enough  extra  work  to  make  up  for  the  skin's  failure,  and 
again  toxic  material  is  retained,  instead  of  being  excreted. 

Treatment  and  Nursing  Care.  As  might  be  expected,  the  de- 
tails of  treatment  and  nursing  care  of  a  pre-eclamptic  patient 
vary  with  different  doctors  and  with  the  severity  of  the  attack. 
But  the  essentials  of  treatment,  the  country  over,  may  be  summed 
up  as  rest  and  elimination,  coupled  with  close  watching  for 
unfavorable  symptoms. 

The  surest  way  to  have  the  patient  really  rest  is  to  put  her 
to  bed,  even  in  mild  cases,  and  recovery  is  so  hastened,  thereby, 
that  she  is  well  paid  for  the  temporary  inconvenience. 

Since  it  is  widely  believed  that  the  metabolic  disturbance, 
in  toxemia,  is  related  to  the  nitrogenous  part  of  the  diet,  the 
course  usually  followed  in  this  particular  is  a  reduction  of  the 
nitrogen  intake.  This  is  accomplished  by  putting  the  patient  on 
a  very  low  protein  diet  or  a  milk  diet,  consisting  of  two  quarts 
of  milk  daily.  This  amount  of  milk  provides  adequate  nourish- 
ment, for  the  time  being,  and  also  supplies  a  large  part  of  the 
fluid  which  is  needed  to  promote  elimination.  In  addition  to 
this,  however,  the  patient  is  given  one,  or  better  still,  two  quarts 
of  water  every  day,  and  free  saline  purges. 

Very  frequently  this  treatment  is  all  that  is  necessary.  The 
blood  pressure  falls  in  a  few  days,  the  albumen  in  the  urine 
gradually  disappears,  the  patient  completely  recovers  and  in 
due  time  has  a  normal  labor. 

But  in  more  severe  and  less  amenable  cases  it  is  necessary 
to  increase  the  eliminative  treatment  and  give  copious  colonic 
irrigations ;  sweat  baths,  in  the  form  of  hot  packs  or  hot  air  baths, 
and  even  venesection  and  saline  infusions,  in  order  to  relieve 
the  symptoms.  Sometimes,  even  these  are  not  enough  and  the 
high  blood  pressure  and  albumen,  Avhicli  are  probably  the  most 
significant  symptoms,  will  continue.  If  so,  and  the  patient  grows 
worse,  or  if  she  simply  fails  to  respond  to  the  treatment,  the 
usual  practice  is  to  induce  labor.  A  daily  output  of  five  grams 
of  albumen  to  a  litre  of  urine,  and  a  blood  pressure  of  200  milli- 
metres are  usually  regarded  as  insistent  indications  that  preg- 
nancy should  be  terminated.     Otherwise^  eclampsia,  always  so 


190  OBSTETRICAL  NURSING 

dreaded,  is  practically  sure  to  follow  and  endanger  the  life  of 
both  mother  and  child. 

It  may  be  mentioned  here  that  the  normal  blood  pressure, 
during  the  latter  part  of  pregnancy,  is  about  120  millimetres. 
A  gradual  increase  to  130,  or  even  140  millimetres,  may  not  be 
serious,  but  a  sudden  rise  or  a  pressure  of  150  millimetres  should 
be  regarded  Avith  alarm,  even  though  all  other  symptoms  be 
absent.  The  reason  for  this  is  that  eclampsia  may,  and  some- 
times does,  occur  with  little  or  no  warning  except  the  high,  or 
suddenly  increasing  blood  pressure. 

Eclampsia.  Pre-eclamptic  toxemia,  as  the  name  suggests,  is 
a  condition  that  frequently  precedes  eclampsia,  and  the  impor- 
tance of  the  prevention,  early  recognition  and  prompt  treatment 
of  this  forerunner  is  due  to  the  seriousness  of  eclampsia  which 
threatens  to  ensue.  This  disease,  which  may  be  defined  as  a  tox- 
emia occurring  before,  during  or  after  labor,  is  one  of  the  gravest 
complications  which  arise  in  obstetrics.  It  is  usually  associated 
with  both  tonic  and  clonic  convulsions,  unconsciousness  and 
coma. 

Patients  who  have  a  tendency  to  kidney  trouble  and  to  di- 
gestive disturbances,  such  as  so-called  "billiousness,"  are  evi- 
dently likely  to  have  eclampsia;  and  in  eclampsia  there  is  a 
peripheral  necrosis  of  the  liver  which  occurs  in  no  other  condi- 
tion. These  facts  suggest  that  possibly  when  metabolism  is  pro- 
ceeding normally,  the  liver  converts  certain  material,  whose  re- 
tention within  the  body  is  inimical  to  health,  into  a  form  which 
the  kidneys  can  excrete  without  great  effort;  that  if  the  liver 
fails  in  this  function,  the  kidneys  are  unable  to  stand  the  in- 
creased strain  put  upon  them,  as  is  evidenced  by  casts  and 
albumen  which  appear  in  the  urine,  and  the  retained  material 
gives  rise  to  toxemia.  It  is  possible  that  disturbed  functions  of 
other  glandular  organs,  such  as  the  thyroid,  may  play  a  part 
in  causing  eclampsia,  but  this,  too,  is  only  conjecture. 

The  frequency  with  which  the  disease  occurs  has  been  vari- 
ously estimated  at  from  one  in  500  to  one  in  100  cases,  appar- 
ently being  more  common  in  first  pregnancies  than  subsequent 
ones,  but  more  serious  when  occurring  among  women  who  have 
had  children  before.     One  attack  is  believed  to  confer  an  im- 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  191 

munity,  or,  as  Dr.  ('lii|)man  puts  it,  "the  woman  with 
eclampsia  vaccinates  herself."  The  average  death  rate  from 
eclampsia  is  from  20  to  35  per  cent,  of  tiie  mothers  and  about  50 
per  cent,  of  tlie  babies,  except  where  the  desired  care  can  be 
given,  either  at  liome  oi-  in  a  iios|)ital,  when  tlie  mortality  is 
greatly  reduced.  Tliese  figures  vai-y,  somewhat,  according  to 
the  time  of  the  onset,  as  the  disease  is  usually  more  fatal  if  the 
convulsions  occur  before  or  during  labor,  than  afterward. 

Some  authoi-ities  feel,  however,  that  eclampsia  is  (juite  as  fatal 
after,  as  before,  labor. 

Symptoms.  The  symptoms,  as  a  rule,  are  those  of  pre-eclamp- 
tic  toxemia  which  have  persisted  and  grown  more  severe,  ac- 
companied by  convulsions  and  coma.  The  blood  pressure  may 
be  from  150  to  250  millimetres  and  the  urine,  in  addition  to 
showing  many  and  varied  casts,  contains  albumen,  which  varies 
in  amount  from  a  few  grams  per  litre  to  more  than  a  hundred  in 
severe  cases.  In  those  cases  which  prove  fatal  and  come  to 
autopsy,  there  is  always  found  a  characteristic,  peripheral  necro- 
sis of  the  liver,  and  since  it  is  found  in  no  other  disease  it  defi- 
nitely establishes  the  diagnosis.  It  is  true  that  this  is  of  no  help 
to  the  poor  woman  who  died,  but  it  is  of  help  to  those  investiga- 
tors who  are  so  earnestly  studying  the  disease  with  the  hope  of 
finding  its  cause  and  cure. 

Although  there  are  frequently  pre-eclaraptic  symptoms  which 
have  grown  worse,  with  or  without  treatment,  it  sometimes  hap- 
pens that  the  patient  has  no  warning  discomfort  and  the  first 
sign  of  the  disease  is  a  convulsion ;  or  a  patient  who  has  been 
treated  for  pre-eclamptie  toxemia  may  apparently  recover,  even 
to  the  extent  of  having  the  albumen  disappear  from  her  urine, 
and  suddenly  have  a  convulsion. 

Convulsions,  which  are  both  tonic  and  clonic  in  character, 
occur  in  about  99.5  per  cent,  of  all  eclamptic  eases  and  are  very 
distressing  to  watch.  They  are  sometimes  preceded  by  an  aura, 
but  often  are  so  unheralded  that  they  may  even  occur  while  the 
patient  is  asleep.  They  ordinarily  begin  witli  a  twitching  of 
the  eyelids;  the  eyes  are  wide  open  and  staring  and  the  pupils 
are  first  contracted  and  then  dilated.  The  twitching  extends  to 
the.  muscles  about  the  nose  and  mouth,  then  to  the  neck  and  arms, 


192  OBSTETRICAL  NURSING 

and  so  on  until  the  entire  body  is  convulsive.  The  patient's  face 
is  usually  cyanotic  and  badly  distorted,  the  mouth  being  drawn 
to  one  side;  she  clenches  her  fists,  rolls  her  head  from  side  to 
side  and  tosses  violently  about  the  bed.  She  is  totally  uncon- 
scious and  insensible  to  light,  and  during  the  seizure  may  not 
breathe  beyond  giving  one  or  two  struggling  gasps.  Her  head 
is  frequently  bent  backward,  her  neck  forming  a  continuous 
curve  with  her  stiffened,  arched  back.  Another  distressing  fea- 
ture is  the  protruding  tongue  and  the  frothy  saliva,  which  is 
blood  stained  if  the  patient  is  not  prevented  from  biting  her 
tongue  by  the  introduction  of  some  sort  of  a  mouth  gag  between 
her  teeth. 

Such  is  the  typical  eclamptic  convulsion. 

The  attacks  vary  greatly  in  their  intensity  and  duration. 
There  may  be  only  a  few  twitches,  lasting  ten  or  fifteen  seconds 
or  violent  convulsions  lasting  as  long  as  two  minutes,  their  num- 
ber and  severity  increasing  with  the  seriousness  of  the  patient's 
condition.  In  mild  cases  there  may  be  but  one  or  two  convul- 
sions, particularly  if  the  onset  is  either  late  in  labor  or  post- 
partum. But  as  a  rule,  there  are  several  convulsions ;  ten,  twenty 
or  thirty,  and  sometimes,  though  rarely,  as  many  as  a  hun- 
dred. 

The  patient  always  goes  into  a  coma  after  a  convulsion  and 
this  also  varies  in  length  and  profundity,  her  condition  during 
the  intervals  being  very  suggestive  of  the  probable  outcome  of 
the  disease.  If  the  attacks  recur  frequently,  as  they  usually 
do  in  extreme  cases,  the  patient  is  likely  to  remain  unconscious 
during  the  entire  interval ;  but  she  will  usually  awaken  between 
attacks  that  are  far  apart,  and  this  is  regarded  as  a  hopeful  sign. 
The  respirations  are  labored  and  noisy  as  a  rule,  and  the  pulse 
full  and  bounding,  in  which  case  the  outlook  is  good.  The  tem- 
perature is  often  normal,  but  may  go  as  high  as  104°  F.  or  105° 
F.,  dropping  rapidly  as  the  attacks  subside.  But  a  weak,  rapid 
pulse  together  with  a  high  temperature,  and  above  all,  a  per- 
sistently high  blood  pressure,  no  matter  what  the  other  symptoms 
may  be,  are  always  unfavorable. 

Concerning  the  varied  results  of  eclampsia,  the  opinion  seems 
to  be  growing  that  if  it  develops  during  late  pregnancy,  labor 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  193 

is  likely  to  set  in  and  a  premature  child  be  born  spontaneously  -, 
in  some  eases,  however,  for  reasons  already  given,  labor  is  in- 
duced, while  in  others  the  mother  dies  undelivered.  The  fetus 
may  die,  after  w^hich  the  convulsions  practically  always  cease 
and  the  infant  is  often  born  later  in  a  macerated  state ;  or  the 
patient  may  recover,  go  to  term  and  give  birth  to  a  normal, 
healthy  baby. 

When  eclampsia  occurs  during  labor  the  pains  usually  in- 
crease in  force  and  frequency,  thus  hastening  delivery,  after 
which  the  convulsions  usually  cease.  It  will  be  noted  that  death 
or  expulsion  of  the  fetus  is  in  almost  all  cases  followed  by  imme- 
diate cessation  of  the  symptoms  and  by  ultimate  recovery. 

Treatment  and  Nursing  Care.  There  is  so  little  definite  in- 
formation about  the  cause  of  eclampsia  that  there  is  quite  nat- 
urally some  difference  of  opiidon  as  to  the  best  methods  of  cura- 
tive treatment.  Unquestionably,  prevention  is  of  first  impor- 
tance and  this  is  accomplished  through  the  watchfulness  and  care 
during  the  antenatal  period  as  described. 

Dr.  Edgar  characterizes  eclampsia  as  a  preventable  disease, 
and  though  an  occasional  ease  will  develop  in  spite  of  preventive 
treatment  the  general  results  achieved  tend  to  bear  out  his  defi- 
nition. For  example,  in  a  series  of  1200  maternity  cases  at  Belle- 
vue  Hospital  during  1920,  prenatal  care  was  given  to  900  women 
and  not  one  case  of  eclampsia  occurred  among  them,  while  among 
the  remaining  .300  women  who  had  not  been  seen  during  preg- 
nancy, there  were  ten  eclamptics.  It  is  but  fair  to  bear  in  mind 
that  as  some  of  these  patients  were  taken  into  tlie  hospital  because 
of  their  having  eclampsia,  the  proportion  is  abnormally  high. 
The  Henry  Street  Settlement  reports  through  its  maternity  ser- 
vice that  there  was  but  one  case  of  eclampsia  among  7600  women 
who  were  given  prenatal  care  bj^  its  nurses  in  1920,  These  fig- 
ures, contrasted  with  the  average  of  one  case  in  about  every  500 
pregnancies,  furnish  astounding  evidence  of  what  can  be  done 
through  i)renatal  care  in  the  prevention  of  this  one  disease  alone. 

As  to  curative  treatment,  the  variations  of  opinion  are  after 
all  of  little  consequence  to  the  nurse,  for  there  is  almost  entire 
■ananimity  concerning  the  general  principles,  and  it  is  these  that 
shape  the  nursing*care.    Broadly  speaking,  they  comprise  effort 


194  OBSTETRICAL  NURSING 

to  dilute  the  toxic  material  in  the  system,  promote  its  elimina- 
tion through  the  various  excretory  channels  and  quiet  the  pa- 
tient's nervous  excitability. 

Since  eclampsia  occurs  only  in  connection  with  pregnancy, 
and  the  convulsions  usually  cease  if  the  fetus  dies  or  is  born,  one 
line  of  reasoning  is  that  the  most  effective  way  to  treat  the  dis- 
ease is  to  terminate  pregnancy.  Formerly  this  was  almost  always 
done,  and  is  still  practised  by  some  obstetricians.  Those  who  do 
not  agree  with  this  theory  contend  that  the  eclamptic  woman  is  a 
very  ill  woman  whose  nervous  system  is  so  irritated  that  the 
slightest  stimulation  or  irritation  works  harm.  In  view  of  this 
they  feel  that  manual  or  instrumental  dilation  of  the  cervix, 
preparatory  to  delivering  the  child  through  that  channel,  or  de- 
livery through  an  incision  in  either  the  abdominal  wall  or  cervix, 
constitutes  a  shock  that  outweighs  the  advantages  of  emptying 
the  uterus;  therefore,  that  as  a  rule,  less  harm  is  done  by  non- 
interference, quieting  the  patient  and  increasing  her  eliminative 
functions,  than  by  terminating  pregnancy.  This  line  of  reason- 
ing also  takes  into  consideration  the  fact  that  from  15  per  cent, 
to  20  per  cent,  of  the  cases  of  eclampsia  are  postpartum,  indicat- 
ing that  convulsions  may  occur  even  after  the  uterus  has  been 
emptied. 

The  growing  tendency  is  to  adopt  a  middle  course  and  treat 
each  individual  case  according  to  the  conditions  and  indications 
which  it  presents.  Thus  the  same  doctor  will  hastily  induce  labor 
in  a  case  where  the  blood  pressure  and  albumen  remain  alarm- 
ingly high,  or  increase,  in  spite  of  all  efforts  to  reduce  them,  and 
in  another  case  will  go  to  the  extreme  of  conservatism,  doing 
nothing  but  quiet  the  patient  with  morphia  or  chloral,  or  both, 
and  stimulate  all  of  her  excretory  organs  with  abundant  fluids. 

But  the  nurse's  duties,  and  I  may  say  her  opportunities,  for 
she  is  privileged  to  do  much,  are  virtually  the  same  no  matter 
which  course  is  followed,  except,  of  course,  the  preparation  for 
delivery,  if  this  is  performed. 

The  nurse  is  concerned  with  helping  to  reduce  the  intake  of 
nitrogenous  food,  or  proteids;  diluting  the  toxines  retained  in 
the  body;  promoting  the  activity  of  the  kidneys,  bowels,  liver, 
lungs  and  skin ;  guarding  the  patient  against  all  avoidable  stim- 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  195 

ulation  from  without,  such  as  noise,  light,  ungentle  handling  and 
undue  resistance  to  the  patient's  convulsive  movements;  and 
protecting  her  from  injuring  herself  by  biting  her  tongue,  falling 
out  of  bed  or  striking  the  wall  or  head  of  the  bed  during  con- 
vulsions. 

By  striving  to  accomplish  these  general  results  for  her  eclamp- 
tic patient  the  nurse  will  aid  immeasurably  in  saving  her  life. 

A  milk  diet  is  the  means  of  reducing  the  nitrogen  intake ;  or 
in  some  cases  even  that  small  amount  of  proteid  is  deemed  too 
much,  and  only  water  is  given  until  24  to  48  hours  after  the  con- 
vulsive seizures  have  ceased.  From  three  to  five  litres  of  these 
fluids  should  be  given  in  the  course  of  twenty-four  hours,  in 
order  to  increase  elimination  by  way  of  both  kidneys  and  skin, 
and  it  usually  taxes  the  nurse's  patience  and  ingenuity  to  give 
this  amount,  for  the  patient  will  seldom  take  large  quantities  of 
fluids  willingly,  even  when  quite  conscious.  A  surprising  amount 
of  water  may  be  giA'en  to  the  sleeping  or  unconscious  patient  by 
dropping  it  into  her  mouth  from  the  point  of  a  teaspoon,  taking 
care  to  give  it  only  at  tliose  moments  when  she  is  lying  quite 
still.  If  the  nurse  attempts  to  hold  the  restless  patient's  head, 
or  so  much  as  places  her  hand  upon  the  chin  to  steady  it  in  order 
to  give  water,  the  irritation,  though  slight,  may  be  enough  to 
cause  a  return  of  the  tossing  and  struggling. 

Litliia  water  and  cream-of -tartar  lemonade  (a  teaspoonful  of 
cream  of  tartar  to  a  pint  of  water),  are  frequently  given  because 
of  their  diuretic  and  diaphoretic  action ;  but  whatever  the  fluid, 
it  must  be  given  persistently,  with  greatest  gentleness  and  with 
care  that  the  patient  does  not  choke  nor  aspirate  it  into  her 
lungs  and  thus  possibly  cause  pneumonia.  Food  even  in  liquid 
form  is  not  given  while  the  patient  is  unconscious,  because  of  this 
danger  of  aspiration  and  subsequent  pneumonia. 

The  bowels  are  stimulated  to  greater  activity  by  powerful 
purges,  such  as  croton  oil,  in  olive  oil,  dropped  on  the  back  of 
the  tongue,  or  salts  or  castor  oil  given  by  stomach  tube. 

Copious  colonic  irrigations^  alternating  with  hot  packs  so 
that  one  or  the  other  is  given  every  six,  eight  or  twelve  hours, 
according  to  the  seriousness  of  the  case,  are  frequently  given  and 
with  excellent  results.     A  colonic  irrigation  may  be  given  by 


196  OBSTETRICAL  NURSING 

means  of  the  Murphy  drip  metliod  or  through  a  rectal  tube  so 
contrived  that  a  two-way  flow  of  fluid  is  possible.  Water,  nor- 
mal saline  (2  drams  of  salt  to  a  quart  of  water),  or  a  weak  solu- 
tion of  sodium  bicarbonate  (an  ounce  of  soda  to  a  quart  of 
water) ,  are  all  used  for  colonic  irrigations,  which  are  given  at  a 
temperature  of  110°  F.,  very  slowly,  with  the  receptacle  for  the 
solution  placed  so  low  that  the  flow  is  under  very  slight  pres- 
sure. The  patient  should  lie  on  her  left  side,  in  a  comfortable 
position  and  be  warmly  covered.  The  tube  should  be  introduced 
from  12  to  18  inches,  and  the  stop  cock  arranged  so  that  it  will 
take  from  twenty  to  thirty  minutes  for  each  gallon  of  fluid  to 
run  in  and  out.  About  two  gallons  are  usually  used  for  the 
first  irrigation,  the  amount  being  increased  until  five  gallons  are 
used  each  time.  The  beneficial  effects  of  the  colonic  irrigations 
are  two-fold,  for  in  addition  to  removing  the  toxic  material  that 
may  be  in  the  colon  and  rectum,  a  good  deal  of  fluid  is  absorbed 
through  the  intestinal  wall. 

The  function  of  the  lungs  may  be  promoted  by  using  oxygen 
and  by  keeping  the  air  in  the  patient's  room  fresh  and  con- 
stantly moving,  but  moving  so  gently  that  there  is  no  perceptible 
draft.  The  nurse  must  remember  that  the  skin  also  is  an  excre- 
tory organ  whose  function  is  being  stimulated,  and  this  necessi- 
tates its  being  kept  warm. 

Some  obstetricians  feel  that  it  is  as  important  to  increase 
the  excretions  of  the  skin  as  of  the  kidneys,  and  that  inability  to 
induce  perspiration  is  an  unfavorable  sign.  Others,  who  dis- 
agree on  this  point,  believe  that  the  skin  is  of  minor  importance 
but  that  the  bowels  are  of  equal  consequence  with  the  kidneys. 
However,  the  nurse  will  do  no  harm,  and  will  err  on  the  safe 
side  if  she  takes  care  to  keep  her  patient  warm  and  constantly 
protects  her  from  being  chilled,  that  is  from  exposure  or  changes 
in  the  temperature  of  her  surroundings.  A  flannel  nightgown 
or  dressing  gown  will  help  to  this  end,  or  if  neither  is  available, 
at  least  the  patient's  chest  and  arms  may  be  protected  by  warm 
bedjacket,  or  sweater,  put  on  backwards  and  fastened  at  the 
back  of  the  neck.  This  protection,  together  with  a  number  of 
blankets,  with  or  without  hot  water  bags  between  them,  will  often 
induce  a  slight  but  constant  perspiration,  particularly  if  fluids 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  197 

by  mouth  are  being  forced  at  the  same  time.  This  may  be  all 
of  the  stimulation  that  the  skin  needs,  and  has  the  advantage  of 
not  greatly  disturbing  the  patient,  a  point  that  cannot  be  too 
constantly  borne  in  mind. 

If  something  more  is  needed,  the  hot  dry  pack  is  a  widely  used 
and  usually  efficacious  method  of  producing  a  sweat  and  can  be 
given  easily  in  the  patient's  home  with  no  more  equipment  than 
the  average  family  possesses  or  can  obtain.  The  articles  needed 
are  two  rubber  sheets  or  two  heavy  quilts ;  four  blankets ;  three, 
four  or  five  hot  water  bags;  an  ice  cap  or  a  basin  with  ice  and 


Fig.  48. — Patient  in  hot  pack  given  Avitli  dry  blankets  and  hot-water 
bags.  The  blankets  are  turned  back  in  this  picture  to  show  their  arrange- 
ment.     (From  photograph  taken  at  Johns  Hopkins  Hospital.) 

two  cloths  for  the  patient 's  head ;  a  pitcher  of  the  fluid  that  she 
is  taking,  and  a  feeding  cup,  drinking  tube,  small  i)itcher  or  a 
spoon  with  which  to  give  it.  One  rubber  sheet  (or  one  of  the 
quilts),  and  two  blankets  should  be  slipped  under  the  patient, 
after  the  regular  bedclothes  have  been  loosened  at  the  foot. 
If  the  patient  is  having  convulsions  it  is  better  to  leave  on 
her  a  warm  garment  with  sleeves  to  insure  against  her  arms 
and  chest  being  uncovered,  otherwise  the  nightgown  may  be 
removed. 

The  patient  is  covered  with  one  blanket  which  is  tucked  be- 


198  OBSTETRICAL  NURSING 

tween  her  legs  and  around  her  body  with  her  arms  out,  so  that 
no  two  surfaces  of  the  skin  come  in  contact.  The  blanket  on 
which  she  lies  is  brought  up  about  her;  another  blanket  should 
be  laid  over  this  and  tucked  in  well  about  the  neck,  shoulders 
and  entire  body,  while  the  fourth  blanket  is  next  wrapped  around 
her  from  below.  One  long  or  tAvo  short  hot  water  bottles  should 
be  placed  on  each  side  of  the  patient  and  one  at  her  feet,  all 
being  placed  outside  the  four  blankets.  The  second  rubber  sheet, 
or  quilt,  is  thrown  over  the  whole  and  the  ice  cap,  or  cold  com- 
presses (changed  every  four  or  five  minutes)  placed  on  her  fore- 
head.    (Fig.  48.) 

A  patient  may  usually  be  left  in  such  a  pack  as  this  from  half 
an  hour  to  an  hour,  but  since  any  sweat  bath  is  more  or  less  de- 
pressing, she  must  be  watched  constantly  for  evidence  of  ex- 
haustion, such  as  a  weak,  rapid,  irregular  pulse  and  increased 
weakness,  or  the  sudden  relaxation  of  an  active  eclamptic  patient. 

In  some  instances  the  hot-water  bags  may  be  inadvisable,  be- 
cause of  supplying  more  heat  than  the  condition  of  the  patient 
warrants;  but  if  they  are  used,  the  nurse  must  remember  how 
easily  an  unconscious  or  ill  person  is  burned.  She  must  watch 
the  bags,  move  them  frequently  and  take  care  that  one  of  them 
does  not  slip  under  the  patient.  And  while  the  pack  is  in  prog- 
ress, an  even  greater  effort  than  ever  should  be  made  to  force 
the  fluids. 

If  the  blankets  are  wrapped  snugly  about  the  patient,  alter- 
nately from  below  and  above  as  described,  they  will  frequently 
provide  all  of  the  restraint  that  is  necessary  should  she  have  a 
convulsion  while  in  the  pack.  The  importance  of  protecting  her 
against  exposure  and  chilling  while  in  the  pack  cannot  be  too 
insistently  stressed. 

If  I  have  seemed  to  dwell  at  surprising  length  upon  rudimen- 
tary nursing  details,  in  this  connection,  it  is  because  the  patient 's 
life  literally  depends  upon  the  nurse's  conscientious  and  pains- 
taking attention  to  these  same  details.  The  doctor  may  study 
the  case  ever  so  earnestly  and  order  the  treatment  ever  so  wisely, 
but  if  every  detail  of  that  treatment  is  not  thoughtfully  and 
skilfully  carried  out,  it  may  do  the  patient  more  harm  than 
good.    And  on  the  other  hand.  I  can  think  of  no  circumstance 


COMPLICATIONS  AND  ACCIDENTS  OP  PREGNANCY  199 

that  gives  the  nurse  deeper  gratification  than  the  almost  miracu- 
lous improvement  in  an  eclamptic  patient,  sometimes  only  over- 
night, after  she  has  taxed  to  the  utmost  all  of  her  ingenuity  to 
make  her  ministrations  effective. 

Appliances  for  giving  hot  packs  and  hot-air  baths  are  usually 
found  in  all  hospitals,  and  the  nurse  will  use  them  as  directed, 
which  obviates  any  necessity  for  describing  them  here.  But  in 
addition  to  correctly  adjusting  and  using  the  appliance  itself, 
she  must  watch  her  patient  for  evidence  of  exhaustion  or  shock ; 
protect  her  from  burns ;  keep  cold  applications  on  her  head  and 
give  her  as  much  fluid  as  possible.  And  when  the  hot  pack  is 
over,  the  patient  must  be  taken  from  it  gradually ;  one  blanket  at 
a  time,  or  the  heat  slowly  reduced,  and  then  the  greatest  care 
taken  that  she  is  not  chilled  while  being  put  into  dry  clothing, 
for  she  must  be  kept  warm  and  perspire  slightly  even  after  the 
sweat  is  finished. 

Restraint  during  convulsions  should  be  as  mild  as  possible, 
for  resistance  only  increases  the  patient's  excitement,  and  sus- 
tained effort  should  be  made  to  reduce  it  instead.  To  this  end 
there  are  innumerable  details  to  be  considered.  Every  act  must 
be  performed  as  quietly  as  possible.  The  nurse  must  walk  lightly 
and  if  her  tread  will  be  made  softer  by  wearing  bedroom  slip- 
pers, she  should  wear  them.  She  should  consciously  guard 
against  kicking  or  striking  the  bed.  All  talking  should  be  in 
low  tones;  doors  opened  and  closed  quietly;  papers  should  not 
be  rustled  nor  furniture  scraped  on  the  floor.  The  room  should 
be  as  dark  as  is  feasible  and  the  source  of  light  screened  fr9m 
the  patient's  eyes. 

She  should  be  saved  from  biting  her  tongue  by  having  placed 
between  her  teeth  something  that  will  serve  as  a  mouth  gag  and 
still  not  cut  nor  bruise  the  mucous  membranes.  In  a  private 
home,  one  will  find  that  a  cork  answers  admirably ;  or  the  handle 
of  a  wooden  spoon  well  wrapped  with  gauze  or  a  clean  handker- 
chief;  or  a  small  roll  of  bandage  or  clean  cloth  tightly  rolled. 
Another  method  is  to  take  a  fresh  handkerchief,  or  napkin,  in 
the  fingers  by  opposite  corners,  twist  it  slightly  into  a  roll  and 
force  it  between  the  teeth  and  tie  the  two  corners  firmly  together 
at  the  back  of  the  neck. 


200  OBSTETRICAL  NURSING 

Venesection.  The  large  intake  of  fluids  tends  to  dilute  and 
eliminate  the  toxins  which  are  giving  so  much  trouble,  but  an- 
other very  prompt  and  efficacious  measure  is  to  withdraw  from 
500  cubic  centimetres  to  1000  cubic  centimetres  of  blood  by 
venesection,  according  to  the  condition  of  the  pulse.  In  prepar- 
ing for  a  venesection  the  nurse  will  slip  a  small  rubber,  covered 
with  a  towel,  under  the  arm  that  is  to  be  opened,  and  scrub  the 
inner  surface  of  the  elboAV  with  soap  and  solutions  according  to 
the  wishes  of  the  doctor  in  charge,  and  cover  the  cleaned  area 
with  a  dry  sterile  towel  or  one  wet  with  a  disinfecting  solution. 
A  sterile  towel  should  be  slipped  under  the  patient's  arm,  one 
laid  over  the  arm  above  and  one  below  the  cleaned  area  so  that 
the  entire  surrounding  field  is  protected  by  sterile  towels. 

For  the  puncture  there  will  be  needed  a  sterile  canula,  or  in- 
fusion needle,  with  a  piece  of  rubber  tubing  attached;  a  sterile 
receptacle  for  the  blood,  usually  a  1000  cubic  centimetre,  gradu- 
ated measuring-glass;  both  dry  and  alcohol  sponges  or  cotton 
pledgets;  adhesive  plaster,  or  a  bandage  to  hold  in  place  the 
small  dressing  which  is  .applied  after  the  needle  is  withdrawn ; 
and  a  tourniquet  for  tight  application  to  the  upper  arm  to  impede 
the  return  of  the  venous  blood  and  thus  distend  the  large  vein  to 
be  seen  near  the  surface  of  the  inner  curve  of  the  arm.  This  vein 
usually  may  be  easily  pierced,  without  incising  the  skin,  the 
canula  pointed  toward  the  hand  to  meet  the  blood  stream,  after 
which  the  tourniquet  is  removed.  Sometimes  it  is  necessary  to 
incise  the  skin  in  order  that  the  vein  may  be  exposed  and  the 
needle  inserted  into  it  directly.  In  this  case  the  doctor  will  need, 
in  addition  to  the  articles  already  mentioned,  a  scalpel,  a  pair  of 
tissue  forceps,  three  or  four  artery  clamps,  a  needle  holder,  skin 
needles  and  sutures. 

A  venesection  is  practically  always  followed  by  a  drop  in  the 
blood  pressure  and  a  marked  improvement  in  the  general  con- 
dition. 

Infusions,  or  subcutaneous  injections  of  saline  solutions,  are 
also  frequently  given  to  eclamptic  patients  with  beneficial  results. 
About  1000  cubic  centimetres  at  105°  F.  is  introduced  slowly  into 
the  tissues,  and  the  solution  may  be  normal  saline,  consisting  of 
two  drams  of  common  salt  to  a  litre  of  distilled  water,  filtered 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  201 

and  sterilized;  or  possibly  one  containing  five  grains  each  of 
sodium  bicarbonate  and  sodium  chloride  to  the  litre. 

The  articles  necessary,  in  addition  to  the  soap  and  solutions 
for  cleaning  up  the  skin,  are  a  small  rubber  to  protect  the  bed; 
three  or  four  sterile  towels ;  a  flask  of  the  solution  at  105°  F. ; 
sterile  infusion  bottle,  or  can,  with  rubber  tubing  fitted  with  a 
piece  of  glass  tubing  at  some  point  in  its  length,  through  which 
the  flow  of  the  solution  may  be  watched,  a  stopcock,  and  an  in- 
fusion needle  (I  cannot  refrain  from  cautioning  the  nurse  to  be 
sure  that  the  tubing  does  not  leak;  is  not  collapsed  and  stuck 
together  at  any  point  along  its  length,  and  that  the  needle  is 
sharp,  free  from  rust  and  contains  a  wire  as  evidence  of  not  being 
clogged) ;  two  hot  water  bottles  about  half  full,  with  air  ex- 
pelled ;  a  pole  or  stand  upon  which  to  hang  the  bottle ;  a  package 
of  gauze  sponges,  or  squares,  and  narrow  strips  of  adhesive. 

The  fluid  is  usually  introduced  between  the  breast  tissues 
and  underlying  muscles;  the  area  to  scrub  up  in  preparation 
being  just  below  the  breast,  where  the  curve  begins,  and  toward 
the  axilla.  The  bottle  which  contains  the  solution  should  be 
stoppered  with  sterile  cotton,  or,  if  a  can,  covered  with  a  sterile 
towel,  and  hung  between  the  hot  water  bottles,  to  keep  the  fluid 
warm,  and  held  in  place  with  a  towel  pinned  around  them,  top 
and  bottom.     (Fig.  49.) 

If  the  nurse  is  to  give  the  infusion,  she  should  grasp  the  end 
of  the  needle,  to  which  the  tubing  is  attached,  with  her  right 
hand,  pierce  a  piece  of  sterile  gauze;  open  the  stop  cock  and 
allow  the  air  and  cold  fluid  to  escape,  leaving  a  drop  on  the  point 
of  the  needle;  lift  the  patient's  breast  with  her  left  hand  and 
quickly  plunge  the  needle  in  just  under  it.  The  direction  of  the 
needle  should  be  parallel  to  the  chest  wall  to  insure  its  running 
below  the  breast  tissue,  and  above,  not  between  the  ribs.  The 
needle,  and  the  gauze  through  which  it  runs,  may  be  held  in 
place  by  means  of  narrow  strips  of  adhesive  plaster.  The  stop 
cock  should  be  so  adjusted  that  the  warm  fluid  will  flow  into  the 
tissues  very  slowly,  about  an  hour  being  required  to  introduce 
1000  cubic  centimetres.  During  this  time  the  patient  must  be 
kept  well  covered  and  the  solution  kept  at  about  105°  F.  as  some 
of  the  heat  is  lost  in  its  course  through  the  tubing.    A  hot  water 


202  OBSTETRICAL  NURSING 


Fig.  49. — Infusion  being  given  under  breast;  needle  held  in  place  by 
strips  of  adhesive  and  the  solution  kept  warm  by  hot-water  bottles  sus- 
pended on  each  side  of  the  infusion  bottle. 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  203 

bag  placed  upon  the  bed,  over  a  coil  of  the  tubing,  is  another 
means  of  maintaining  the  desired  temperature,  but  it  must  be 
watched  and  mo-ed  from  time  to  time,  to  guard  against  burning 
the  patient.  In  hospitals  where  the  infusion  apparatus  is 
equipped  with  a  heater,  hot  water  bags  are,  of  course  not  needed, 
but  they  are  of  practical  service  in  a  patient's  home. 

Termination  of  pregnancy  is  resorted  to  much  less  frequently 
than  formerly,  because  it  is  believed  that  an  eclamptic  patient 
is  particularly  susceptible  to  infection  and  also  that  the  shock 
of  an  induced  labor  is  serious  to  so  ill  a  woman. 

The  method  of  terminating  pregnancy,  when  this  is  finally 
deemed  necessary,  depends  upon  the  condition  of  the  cervix ;  the 
size  of  the  child;  and  upon  the  patient's  general  condition.  The 
method  may  be  simple  induction  of  labor,  by  the  introduction 
of  a  bougie,  if  haste  is  not  imperative;  introduction  of  a  bag; 
manual  dilation  of  the  cervix,  if  it  is  soft  and  partly  obliterated ; 
vaginal  hysterectomy,  or  even  cesarean  section. 

Chloroform  is  not  used  as  an  anesthetic,  in  eclampsia,  nor 
to  relieve  the  labor  pains  nor  control  the  convulsions  because  of 
its  tendency  to  increase  the  liver  necrosis  which  is  incidental  to 
the  disease. 

Recovery  is  comparatively  rapid,  when  it  occurs.  The  blood 
pressure  drops  to  normal ;  the  albumen  and  casts  disappear  from 
the  urine  and  all  symptoms  subside  in  from  two  to  four  weeks. 
(Chart  I.)  And,  happily,  since  one  attack  confers  an  immunity, 
the  patient  who  recovers  from  eclampsia  need  not  fear  a  recur- 
rence of  the  disease. 

Nephritic  Toxemia  is  a  serious  toxemia,  sometimes  compli- 
cating pregnancy,  and  though  it  may  occur  at  anj^  time  during 
the  period  of  gestation,  it  usually  develops  during  the  latter 
months.  As  a  rule,  it  is  simply  an  exacerbation  and  accentuation 
of  a  previously  existing,  chronic  nephritis,  of  which  the  patient 
may,  or  may  not,  have  been  aware ;  though  in  some  instances  the 
disability  of  the  kidneys  may  arise  during  pregnancy.  In  many 
cases,  so  far  as  the  kidneys  are  concerned,  the  patient  is  entirely 
normal  in  the  non-pregnant  state,  and  even  during  pregnancy,  up 
to  a  certain  point;  then  her  kidneys  prove  to  be  unequal  to  the 


204 


OBSTETRICAL  NURSING 


added  metabolic  strain  of  pregnancy,  and  signs  of  renal  insuffi- 
ciency appear. 

Such  a  patient  will  suffer  from  toxemia,  with  each  recurring 

Name  vA^^I^^eAV.  MS. 

Date  -^-^^fi•    ^  ^C'..r...Ai\ 


Cram*  y 
Alb.per/\  eo  ^ 
Liter. 


Chart  1. — Chart  showing  relatively  rapid  disappearance  of  albumen 
from  the  urine  and  return  of  blood  pressure  to  normal,  after  delivery  in 
eclampsia. 

pregnancy,  the  symptoms  almost  always  appearing  earlier,  and 
with  increased  severity,  with  each  pregnancy,  as  the  permanent 
damage  to  the  kidneys  is  increased  by  each  successive  attack. 
Syiiiptoins.       The  symptoms  in  nephritic  toxemia  are  prac- 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  205 

tically  the  same  as  those  in  chronic  nephritis:  lassitude,  head- 
ache, visual  disturbances,  edema,  high  blood  pressure  and  casts 
and  large  amounts  of  albumen  in  the  urine.  In  some  instances, 
the  patient  suffers  such  slight  discomfort  that  the  increased  blood 
pressure  and  urinary  symptoms  are  the  only  precursors  of  coma, 
and  possibly  convulsions  which  cannot  be  distinguished  from  an 
eclamptic  seizure. 

As  the  patient  may  die  in  the  coma,  no  matter  how  suddenly 
it  develops,  the  value  of  regular  urinalyses  and  observations  upon 
the  blood  pressure,  which  are  included  in  prenatal  care,  must 
once  more  be  mentioned. 

In  severe,  chronic  cases  infarcts  (hemorrhagic  or  necrotic 
areas)  appear  in  the  placenta.  These  may  be  extensive  enough 
to  interfere  with  the  nourishment  of  the  fetus,  which,  being  al- 
ready weakened  by  the  toxic  effects  of  the  disease,  is  unable  to 
survive.  As  a  result,  nephritic  toxemia  is  second  only  to  syphilis 
in  causing  premature  deaths.  When  the  child  dies,  the  symptoms 
usually  begin  to  subside  in  a  week,  or  possibly  two,  and  the  dead 
fetus  is  expelled. 

Treatment  and  Nursing  Care.  The  treatment  and  nursing 
care  are  virtually  the  same  as  for  pre-eclamptic  toxemia ;  rest 
in  bed,  milk  diet,  forced  fluids,  purges,  and  in  addition,  observa- 
tions upon  the  intake  and  output  of  fluids.  The  output  of  urine 
will  not  equal  the  amount  of  fluid  which  the  patient  takes  in, 
at  first,  but  in  those  patients  who  improve,  the  amount  of  urine 
gradually  increases  until  it  equals  the  amount  of  fluid  ingested. 
The  edema  and  other  symptoms  improve,  except  the  high  blood 
pressure  and  the  albumen  in  the  urine,  which  sometimes  persist 
for  months.     (Chart  2.) 

If  the  patient  has  coma  or  convulsions,  the  treatment  is  the 
same  as  in  eclampsia. 

A  patient  with  inadequate  kidneys  who  has  never  been  able 
to  carry  a  child  to  term  may  sometimes  achieve  this  coveted  end 
by  going  to  bed  a  few  weeks  before  the  period  in  her  pregnancy 
Avhen  the  toxic  symptoms  have  usually  appeared,  taking  only 
milk  for  food,  drinking  large  amounts  of  water,  and  keeping 
her  bowels  moving  freely. 

It  is  impossible  to  distinguish  between  eclampsia  and  neph- 


206 


OBSTETRICAL  NURSING 


ritic  toxemia  during  an  attack,  but  this  is  of  no  importance  at 
the  time,  as  the  treatment  of  the  two  diseases  is  the  same. 

But  during  the  puerperium,  the  differential  diagnosis  may  be 
made,  for  in  eclampsia  the  blood  pressure  falls  rapidly  to  nor- 

Name  .^u5iavj.  ASA!a\Xito.  Ward -aXAjCm--. 
Date..j5-ft.3A,>.....\,lo...*.W. _ 

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Chart  2. — Chart   showing  persistence  of  high  blood  pressure   and   of 
albumen  in  the  urine,  after  delivery,  in  nephritic  toxemia  with  convulsions. 


mal  and  the  casts  and  albumen  disappear  from  the  urine  in  from 
two  to  four  weeks.  In  nephritic  toxemia,  on  the  other  hand,  al- 
though the  blood  pressure  falls  somewhat,  and  the  albumen  de- 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  207 

creases  in  amount  as  the  patient's  general  condition  improves, 
by  the  end  of  the  puerperium  the  blood  pressure  is  still  elevated 
and  casts  and  albumen  are  still  present  in  the  urine. 

In  eclamptic  cases  that  come  to  autopsy,  there  is  a  typical, 
peripheral  necrosis  of  the  liver,  but  in  nephritic  toxemia  there 
is  no  liver  lesion. 

Acute  Yellow  Atrophy  of  the  Liver  is  one  of  the  grave 
but  very  rare  toxemias  of  pregnancy  and  though  it  may  occur  at 
any  stage  it  usually  appears  during  the  latter  part  of  pregnancy 
or  during  the  puerperium.  This  complicating  condition  is  not 
peculiar  to  pregnancy  alone,  although  from  forty  to  sixty  per 
cent,  of  the  cases  which  occur  are  in  pregnant  women. 

The  symptoms,  which  sometimes  come  on  suddenly  in  a 
woman  who  previously  has  been  entirely  well,  may  suggest  phos- 
phorus poisoning.  They  are  abdominal  pain,  headache,  vomiting, 
and  diarrhea  followed  in  some  cases  by  coma  and  convulsions,  and 
in  others  by  violent  delirium.  With  these  symptoms  are  jaun- 
dice and  a  diminished  amount  of  urine,  which  contains  albumen, 
casts,  and  usually  a  good  deal  of  blood.  The  picture  is  practically 
that  of  pernicious  vomiting  plus  jaundice  and  pain. 

Little  is  known  of  the  ultimate  cause  of  the  disease,  but  it 
produces  rapid  atrophic  and  degenerative  changes  in  the  liver, 
and  though  mild  cases  sometimes  recover,  the  outcome  is  usually 
fatal.  It  was  formerly  thought  that  the  termination  of  preg- 
nancy virtually  cured  the  condition,  but  the  present  belief  is 
that  delivery  produces  little  or  no  effect.  The  tendency  now, 
therefore,  is  simply  to  employ  the  same  kind  of  eliminative  treat- 
ment that  is  used  in  eclampsia. 

Among  the  more  serious  complications  of  pregnancy,  which 
are  not  due  to  that  condition,  but  which  it  is  important  to  recog- 
nize and  treat  early,  may  be  included  syphilis,  heart  lesions, 
pulmonarj'  tuberculosis,  thyroidism,  gonorrhea  and  pyelitis. 

"Syphilis  is  one  of  the  most  important  complications  of 
pregnancy,"  in  the  opinion  of  Dr.  Williams,  "as  it  is  the  most 
important  single  cause  of  fetal  death." 

In  support  of  this  contention,  Dr.  Williams  reports  upon  a 
series  of  10,000  consecutive  deliveries  which  took  place  under  his 
observation,  and  in  which  syphilis  caused  26.4  per  cent,  of  the 


208  OBSTETRICAL  NURSING 

deaths  among  705  babies  who  died  after  the  seventh  month  of 
pregnancy  or  during  the  first  two  weeks  after  birth.  Further- 
more, nearly  as  many  more  babies  who  were  discharged  alive,  at 
the  age  of  two  weeks,  died  in  a  short  time  or  gave  evidence  of 
having  syphilis  later  on  in  life. 

Believing  in  the  importance  of  diagnosing  and  treating  this 
disease  during  pregnancy,  Dr.  AVilliams  subsequently  made  obser- 
vations upon  4,000  cases  in  which  Wassermann  tests  were  given, 
and  to  which  421  women  gave  positive  reactions.  In  this  series 
of  4,000  deliveries,  302  babies  died  during  the  last  two  months 
of  uterine  life,  or  the  first  two  weeks  of  extra-uterine  existence. 
The  relative  frequency  of  the  various  causes  which  worked  de- 
struction in  these  302  little  lives  is  given  by  Dr.  Williams  in  the 
following  table : — 

Syphilis   104  cases  34.44% 

Dystocia '. . .  46  " 15.20  " 

Toxemia  35  "  11.55" 

Prematurity    32  "  10.59 " 

Cause  unknown 26  "  8.61 " 

Placenta    praevia    and    i^remature 

separation 16  "  5.28 " 

Deformity 11  "  3.64 " 

Eleven  other  causes ' . .  32  "  10.69  " 


Total 302  100.00  " 

It  will  be  seen  from  these  figures  that  syphilis  caused  almost 
as  many  deatlis  as  the  three  causes,  next  in  order,  combined. 

The  effect  upon  the  child's  chances  for  life,  of  treating  the 
expectant  mother  for  syphilis,  is  suggested  by  comparing  the 
results  among  the  421  syphilitic  women  who  were  not  treated  at 
all;  those  treated  insufficiently  by  receiving  but  two  or  three 
doses  of  salvarsan  and  no  after-treatment  of  mercury  (because  of 
the  patient's  lack  of  cooperation  or  because  treatment  was  in- 
stituted too  late  in  pregnancy)  ;  and  those  treated  satisfactorily, 
which  meant  the  administration  of  from  four  to  six  doses  of  sal- 
varsan followed  by  mercurial  treatment  continued  sufficiently 
long  to  result  in  a  Wassermann  reaction  that  was  negative,  and 
remained  so. 

Among  those  mothers  who  were  not  treated,  52  per  cent,  of 
the  babies  were  born  dead  or  had  syphilis ;  among  those  treated 


COMPLICATIONS  AND  ACCIDENTS  OP  PREGNANCY  209 

incompletely,  37  per  cent,  and  among  those  treated  until  cured, 
syphilis  caused  the  death  of  or  was  demonstrable  in  but  6.7 
per  cent,  of  the  babies.^ 

The  deductions  to  be  made  from  these  dramatic  figures  is, 
that  although  syphilis  seems  to  have  about  the  same  effect  upon 
the  pregnant,  as  the  non-pregnant  woman,  it  constitutes  a  seri- 
ous menace  to  infant  life  and  health. 

Accordingly,  it  is  very  important  that  every  pregnant 
woman  be  given  the  Wassermann  test  as  early  as  the  third  or 
fourth  month,  and  any  woman  who  gives  a  positive  reaction 
should  be  urged  to  submit  to  intensive  treatment  until  cured. 
Her  compliance  will  apparently  multiply  by  seven  or  eight  her 
expected  baby's  chances  for  life. 

Heart  Lesions  sometimes  present  grave  complications  dur- 
ing pregnancy,  or  at  the  time  of  labor,  because  the  damaged  or 
weakened  heart  is  unable  to  meet  the  greatly  added  strain  put 
upon  it  at  these  times.  Spontaneous,  premature  labor  sometimes 
results  from  serious  heart  trouble,  while  in  some  cases  labor  is 
artificially  induced  to  relieve  the  overworked  organ  of  the  strain 
that  is  evidently  exhausting  it.  Quite  obviously  it  is  an  im- 
portant step  toward  the  prevention  of  both  these  deplorable 
occurrences  to  have  the  difficulty  recognized  early.  Rest  in  bed 
and  the  same  kind  of  medical  treatment  that  would  ordinarily  be 
given  for  a  poorly  compensating  heart  will  sometimes  enable  the 
disabled  organ  to  carry  its  load  throughout  pregnancy.  But  care 
is  necessary. 

Pulmonary  Tuberculosis  is  so  common  under  all  condi- 
tions that  it  is  not  surprising  to  find  it  fairly  often  among  preg- 
nant women.  Since  the  treatment  for  this  disease  consists 
largely  of  effort  to  conserve  the  patient's  forces  and  build  up  the 
bodily  resistance,  the  drain  which  pregnancy  makes  upon  the  sys- 
tem is  likely  to  be  inimical  to  the  tuberculous  patient 's  improve- 
ment.   It  is  the  general  opinion,  therefore,  that  the  tuberculous 

^  * '  The  Value  of  the  Wassermann  Keaction  in  Obstetrics,  Based  upon 
the  Study  of  4,547  Consecutive  Cases."  Johns  Hopkins  Hospital  Bulletin, 
Oct.,  '20.  ' '  The  Significance  of  Syphilis  in  Prenatal  Care  and  in  the. 
Causation  of  Infant  Death. ' '  Johns  Hopkins  Hospital  Bulletin,  May, 
1921. 


210  OBSTETRICAL  NURSING 

patient  grows  worse  during  pregnancy,  and  is  still  further  weak- 
ened by  the  ordeal  of  labor  and  the  drain  of  nursing  her  baby. 

Some  women  with  tuberculosis  improve  during  the  period 
of  pregnancy,  but  decline  after  delivery.  The  disease  may  ad- 
vance rapidly  in  such  cases  and  the  patient  succumb  very  .early. 

There  is  gi'eat  reluctance  to  terminate  pregnancy  in  tubercu- 
lous patients,  except  in  extreme  cases  as  a  last  resort,  to  save 
the  mother's  life,  or  when,  after  the  child  is  viable,  its  chances 
for  life  would  seem  to  be  better  if  it  were  brought  into  the  world, 
because  of  the  mother's  possible  death. 

Certain  it  is  that  the  care  which  is  given  to  the  non-pregnant 
tuberculous  person  is  needed  to  an  even  greater  degree  by  the 
expectant  mother  who  is  suffering  from  this  disease.  And  under 
such  care,  it  not  infrequently  happens  that  the  patient  will  go 
through  pregnancy  safely,  and  if  the  care  is  continued  after  de- 
livery, and  her  baby  not  allowed  to  nurse,  her  ultimate  recovery 
does  not  seem  to  be  retarded  by  the  experience. 

Tuberculosis  is  sometimes,  though  not  frequently,  transmitted 
from  the  mother  to  the  fetus;  but  babies  born  of  these  mothers 
are  not  likely  to  be  robust,  particularly  as  they  must  be  deprived 
of  that  bulwark  of  early  infancy — maternal  nursing. 

Thyroidism  in  pregnancy  has  been,  and  still  is,  so  widely 
discussed  and  studied  that  the  nurse  will  do  well  to  at  least  take 
cognizance  of  that  fact,  even  though  no  definite  conclusions  seem 
to  have  been  generally  accepted. 

The  toxemias  of  pregnancy  are  so  shrouded  in  mystery,  and 
knowledge  of  the  functions  and  inter-relations  of  the  ductless 
glands  is  still  so  meagre,  though  it  is  known  that  one,  the  ovary, 
is  inevitably  concerned  with  pregnancy,  that  one  is  not  surprised 
to  find  certain  investigators  considering  these  two  problems  to- 
gether. Nor  is  it  surprising  that  directly  opposite  views  are  held 
concerning  the  relation  of  thyroidism  to  toxemia. 

Since  the  nurse  will  sometimes  care  for  toxemic  patients  who 
are  treated  for  thyroidism,  either  by  means  of  gland  therapy  or 
operative  procedure,  she  should  understand  the  rationale  of  such 
treatment  when  she  meets  it. 

Dr.  Williams  says,  for  example,  "A  considerable  amount  of 
work  has  been  done  in  this  direction,  but  the  consensus  of  opin- 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  211 

ion  is  that  abnormalities  of  the  thyroid  secretion  play  no  part  in 
the  causation  of  eclampsia." 

On  the  other  hand,  it  will  be  remembered  that  the  thyroid 
gland  is  usually  somewhat  enlarged  during  pregnancy,  and  in 
this  connection  Dr.  Edgar  observes  that  "The  normal  enlarge- 
ment of  this  organ  in  tlie  gravida  has  been  wanting  in  certain 
cases  of  eclampsia. ' ' 

Dr.  Edward  P.  Davis  summarizes  his  opinions  on  the  subject 
as  follows:  "Hyper-thyroidism  in  pregnancy  produces  a  toxic 
condition  in  the  mother,  which  exposes  her  to  the  danger  of  the 
toxemia  of  pregnancy  and  her  child  to  the  dangers  which  accom- 
pany that  condition.  During  pregnancy,  the  patient  has  a  rapid 
pulse,  often  with  high  tension,  and  attacks  of  breathlessness  and 
syncope,  and  intense  nervousness.  When  uterine  contractions 
begin,  the  action  of  the  heart  becomes  exceedingly  rapid;  there 
is  difficulty  in  breathing  and  the  patient  is  brought  into  great 
distress.  It  is  often  necessary  to  give  prompt  assistance  in  la- 
bor, and  this  may  require  the  performance  of  cesarean  section. 
The  child  is  exposed  to  the  risks  of  rapid  delivery,  although,  if 
section  be  performed,  the  risk  to  the  child  is  reduced  to  the  low- 
est point.  When  the  placenta  is  examined,  it  is  found  that  cer- 
tain changes  have  taken  place  in  its  structure  which  interfere 
with  the  circulation  of  the  blood  through  the  placenta,  and  may 
indirectly  bring  about  the  death  of  the  fetus.  The  child  is  also 
subject  to  the  same  toxic  conditions  ^diich  the  mother  has  had 
and  may  die  from  failure  of  the  liver  and  kidneys  or  in  con- 
valescence. 

"A  minute  discussion  of  the  subject  would  be  occupied 
largely  by  the  question  of  exactly  what  are  the  poisons  which 
cause  this  condition,  and  this  question  has  not  yet  been  definitely 
answered. 

"So  far  as  neutralizing  the  results  of  excessive  action  of  the 
thyroid,  it  is  best  accomplished  by  rest,  a  diet  from  which  meat 
and  other  heavy  proteins  are  excluded,  regulation  in  the  action 
of  the  bowels  and  the  avoidance  of  nervous  excitement  or  undue 
exertion.  If  the  action  of  the  heart  is  excessively  disturbed, 
those  drugs  which  control  cardiac  action  must  be  used.  In  ex- 
treme cases,  morphine  and  atropine  are  given." 


212  OBSTETRICAL  NURSING 

Pyelitis  is  a  fairly  common,  and  sometimes  a  very  painful 
and  serious  complication  arising  during  the  latter  half  of  preg- 
nancy. It  is  an  inflammation  of  the  pelvis  of  the  kidney,  most 
frequently  the  right,  caused  by  a  damming  back  of  urine,  because 
of  pressure  of  the  enlarged  uterus  on  the  ureter  where  it  crosses 
the  pelvic  brim ;  and  by  infection,  which  may  travel  up  from  the 
bladder  or  be  conveyed  by  the  lymph  and  blood  streams,  fre- 
quently from  the  intestines.  The  colon  bacillus  is  the  commonest 
offender,  though  the  streptococcus,  gonococcus  or  even  the 
tubercle  bacillus  may  be  the  cause. 

Frequently  the  patient  will  be  entirely  well,  aside  from  a 
slight  irritability  of  the  bladder  causing  frequent  micturition, 
and  suddenly  have  paroxysms  of  acute  pain  in  the  region  of  the 
kidney,  which  may  be  swollen  and  very  painful  on  palpation. 
She  will  have  fever  and  sometimes  chills  and  a  catheterized  speci- 
men of  urine  will  contain  pus  and  bacteria.  The  kidney  may 
suddenly  empty  itself  of  pus  after  which  the  pain  and  swelling 
will  subside,  only  to  recur  when  the  pus  accumulates  again. 

The  treatment  is  rest  in  bed,  a  bland  diet  and  an  abundance 
of  milk  and  water  to  drink.  As  the  infection  is  often  of  intes- 
tinal origin,  drugs  are  usually  given  to  prevent  intestinal  fer- 
mentation and  keep  the  bowels  moving  freely.  Sometimes, 
though  rarely,  when  the  patient  does  not  improve  under  treat- 
ment, pregnancy  is  terminated  to  relieve  the  pressure  on  the 
ureter  and  thus  drain  the  diseased  kidney  by  permitting  an  un- 
obstructed flow  of  urine. 

The  tendency  of  the  disease  is  to  subside  spontaneously,  but 
sometimes  it  is  necessary  to  incise  and  drain  the  kidney,  or  even 
to  remove  it ;  while  in  others  the  infection  is  so  virulent  that  the 
patient  dies  of  septicemia. 

Gonorrhea  during  pregnancy  may  cause  great  discomfort 
in  the  shape  of  irritation  and  itching  of  the  vulva,  or  even  ex- 
coriation of  the  mucous  membrane,  and  sometimes  abscesses  of 
the  vulvovaginal  glands.  Occasionally  the  infection  reaches  the 
decidua  and  causes  an  abortion.  But  the  chief  danger  in  gonor- 
rhea is  that,  after  delivery,  if  the  disease  has  remained  uncured, 
the  organisms  may  travel  up  from  the  vagina  to  the  uterine  cav- 
ity and  tubes,  and  there  set  up  an  inflammation,  or  possibly  cause 


COMPLICATIONS  AND  ACCIDENTS  OF  PREGNANCY  213 

a  general  postpartum  infection.  The  greatest  danger  to  the  child 
is  that  its  eyes  may  become  infected  during  the  passage  of  the 
head  through  the  birth  canal.  This  is  the  reason  for  the  very 
great  care  that  is  taken  of  the  eyes  of  the  newborn,  which  will 
be  described  in  a  later  chapter. 

It  is  very  important,  therefore,  for  the  sake  of  both  mother 
and  child,  that  gonorrhea  be  discovered  early,  for  treatment 
started  at  this  stage  is  often  attended  by  very  gratifying  results, 
as  the  disease  may  be  entirely  cured  before  it  is  able  to  invade  the 
uterus  and  tubes.  This  is  because  the  closure  of  the  internal  os, 
by  the  membranes,  converts  the  vagina  and  cervix  into  more  or 
less  of  a  cul-de-sac,  to  which  the  infection  is  restricted.  Being 
thus  localized,  it  may  often  be  eradicated  with  relatively  little 
trouble. 

The  yellow  vaginal  discharge,  characteristic  of  gonorrhea, 
may  become  profuse  and  purulent.  It  is  removed  by  means  of 
low,  very  gently  given  douches.  Tampons  and  vaginal  supposi- 
tories are  sometimes  used,  while  abscesses  and  abrasions  are  given 
appropriate  surgical  treatment. 

The  nurse  must  observe  the  strictest  technique  while  caring 
for  these  patients  because  of  the  danger  of  infecting  herself  and 
others  with  the  discharges.  She  should  wear  a  gown  and  rubber 
gloves  when  giving  douches  or  dressing  diseased  vulva,  and  be- 
cause of  the  possibility  of  contamination  by  splashing  fluids,  she 
should  hold  her  head  well  to  one  side  in  addition  to  protecting 
her  eyes  with  goggles.  All  utensils  for  each  patient  should  be 
isolated  and  they  should  also  be  washed  and  boiled  after  each 
time  that  they  are  used. 


"Lying-in  is  neither  a  disease  nor  an  accident,  and  any 
fatality  attending  it  is  not  to  be  counted  as  so  much  per  cent,  of 
inevitable  loss.  On  the  contrary,  a  death  in  child-bed  is  almost 
a  subject  for  an  inquest.  It  is  nothing  short  of  a  calamity  which 
it  is  right  that  we  should  know  all  about,  to  avoid  it  in  future." 

Florence  Nightingale. 


PART  IV 

The  Birth  of  the  Baby 

chapter  x.    presentation  and  position  of  the  fetus. 

Breech,  Head,  Face,  and  Vertex  Presentations.  Longitudinal  and 
Transverse  Presentations.  Position  of  Fetus.  Time  of  Engage- 
ment. Methods  of  Ascertaining  Position  and  Presentation  of  Fetus. 
Abdominal  Palpation.  Vaginal  Examination.  Rectal  Examination. 
Auscultation  of  the  Fetal  Heart. 

CHAPTER  XI.  SYMPTOMS,  COURSE,  AND  MECHANISM  OF  NOR- 
MAL LABOR.     Onset  of  Labor.     Three  Stages  of  Labor. 

CHAPTER  XII.  NURSE'S  DUTIES  DURING  LABOR.  General  Prin- 
ciples of  Treatment  and  Nursing  Care.  Psychology  of  the  Patient. 
Preparation  for  Vaginal  Examination  or  Delivery.  Nurse 's  Duties 
during  First  Stage.  Second  Stage.  Maintaining  of  Surgical  Cleanli- 
ness. Immediate  Care  of  the  Child.  Resuscitation  of  New-born 
Child.  Third  Stage.  Immediate  Aftercare  of  the  Patient.  Nurse 's 
Duties  if  the  Doctor  Is  Delayed.  Prolapsed  Cord.  Post-partum 
Hemorrhage.  Obstetrical  Anesthesia:  Chloroform.  Ether.  Nitrous 
Oxide  Gas  Analgesia.     Twilight  Sleep.     Complete  Anesthesia. 

CHAPTER  XIII.  OBSTETRICAL  OPERATIONS  AND  COMPLICATED 
LABORS.  Conditions  Giving  Rise  to  Operations.  Preparation  for 
Operation  in  the  Home.  Perineal  Lacerations.  Episiotomy.  Breech 
Extraction.  Version.  The  Use  of  Forceps.  Symphysiotomy. 
Vaginal  Hysterotomy.  Cesarean  Section.  Ruptured  Uterus.  De- 
structive Operations.  Induced  Abortions  and  Premature  Labors. 
Accouchment  Force. 


CHAPTER  X 

PRESENTATION  AND  POSITION  OF  THE  FETUS 

Returning  for  a  moment  to  the  pregnant  uterus  at  term,  we 
find  it  to  be  a  thin-walled,  muscular  sac  containing  the  mature 
fetus,  attached  by  means  of  the  umbilical  cord  to  the  placenta 


Pio.  50. — Most  frequent  attitudfe  of  fetus  in  uterine  cavity,  at  term. 

217 


218 


OBSTETRICAL  NURSING 


and  floating  in  the  amniotic  fluid,  which  is  contained  within  a 
sac  formed  by  the  amniotic  and  chorionic  membranes. 

The  average  fetus  at  term  is  about  50  centimetres  long, 
weighs  about  3250  grams  and  is  curved  and  folded  upon  itself 
into  an  ovoid  mass,  occupying  the  smallest  possible  space.  (Fig. 
50.)  Its  most  frequent  attitude  is  with  the  back  arched ;  the  head 
bent  forward,  with  chin  resting  upon  chest;  arms  crossed  upon 
chest  below  chin ;  thighs  flexed  upon  abdomen  and  knees  bent. 

With  a  few  exceptions  the  long  axis  of  the  fetus  is  parallel  to 
the  long  axis  of  the  mother,  and  most  frequently  the  head  is 


Fig.  51. — Illustrations  from  the  first  textbook  on  obstetrics,  Koesslin's 
"  Rosengarten, "  1513,  which  gives  an  amusing  impression  of  early  ideas 
of  the  position  of  the  fetus  in  utero. 


PRESENTATION  AND  POSITION  OF  THE  FETUS    219 

downward.  It  was  formerly  believed  that  the  child  stood  upright 
in  the  uterus  until  toward  the  end  of  pregnancy  and  then  somer- 
saulted to  the  position  it  occupied  immediately  before  birth. 
(Fig.  51.)  But  it  is  now  known  that  though  the  fetus  may  move 
about  and  change  its  position  during  the  early  part  of  preg- 
nancy, it  is  not  likely  greatly  to  alter  its  relation  to  the  mother's 
body  during  tlie  tenth  lunar  month. 

It  seems  advisable  to  define  here  certain  terms  which  are  in 


Fig.   52. — Attitude  of   fetus  in  breech   presentation. 

common  use  in  discussing  patients  in  labor,  and  which  will  be 
employed  in  the  following  pages. 

A  nullipara  (0-para)  is  a  woman  who  has  not  had  children. 

A  primigravida  is  a  woman  who  is  pregnant  for  the  first  time. 

A  primipara  (1-para)  applies  to  a  woman  during  her  first  labOr  and 
until  the  beginning  of  her  second  labor. 

2-para,  3-para  and  4-para  apply  to  women  in  succeeding  labors 
which  correspond  to  the  numerals  used. 

A  multipara  is  a  woman  who  has  had  more  than  one  child. 


220 


OBSTETRICAL  NURSING 


There  is  also  a  terminology,  with  abbreviations,  -which  is 
fairly  generally  used  in  this  country  and  England  to  designate 
the  position  which  the  child,  about  to  be  born,  occupies  in  rela- 
tion to  its  mother's  body.  A  diagnosis  of  this  position  is,  of 
course,  absolutely  necessary  to  a  skilful  management  of  labor, 
and  the  nurse  should  understand  the  meanings  of  the  terms  used, 
and  also  their  distinctions  and  subdivisions. 

The  presentation  of  the  fetus  is  the  term  which  is  employed 


Fig.   53. — Attitude  of   fetus   in  vertex  presentation. 

to  indicate  the  part  of  the  baby's  body  which  is  at  the  brim  of 
the  mother's  pelvis.  Thus  the  part  of  the  fetus  which  is  lower- 
most is  designated  as  the  presenting  part  and  gives  the  presenta- 
tion its  name.  If  the  breech  is  downward,  therefore,  it  is  a 
hreech  presentation  (Fig.  52),  and  if  the  head  is  the  lower  pole 
it  is  termed  a  head,  or  cephalic  presentation.  (Fig.  53.)  The 
head  presentations  are  divided  into  two  main  groups,  which  are 
designated,  respectively,  as  face  and  vertex  presentations.      For 


PRESENTATION  AND  POSITION  OF  THE  FETUS     221 

example,  if  the  baby 's  neck  is  so  arched  that  the  chin  rests  upon 
the  chest,  the  crown  of  its  head,  or  the  vertex,  is  the  part  that 
is  lowest  in  the  birth  canal  and  is  the  part  that  will  be  seen 
first  at  the  vaginal  outlet.  Therefore,  this  is  called  a  vertex,  or 
occipital  presentation.  But  if  the  neck  is  bent  sharply  back- 
ward, the  face  becomes  the  presenting  part  and  we  have  a  face 
presentation. 

The  breech,  face  and  vertex  presentations  are  sometimes  re- 
ferred to  as  longitudinal  presentations  since  in  these  instances  the 
long  axes  of  the  bodies  of  mother  and  child  are  parallel.  In 
transverse  presentations,  however,  the  child  lies  across  the  uterus, 
with  one  side  or  the  other  at  the  pelvic  brim. 

The  transverse  presentations  are  infrequent,  occurring  once 
in  about  250  cases,  and  are  regarded  as  abnormal  because  spon- 
taneous delivery  under  such  circumstances  is  extremely  rare. 
They  are  more  likely  to  be  seen,  w^hen  they  do  occur,  among 
multiparas  and  w^omen  who  have  contracted  pelves. 

The  longitudinal  presentations,  however,  constitute  something 
over  99  per  cent,  of  all  cases  and  are  regarded  as  normal,  since 
the  child  occupying  this  relationship  may  be  born  spontaneously. 
In  about  3  per  cent,  of  the  longitudinal  presentation  the  breech 
is  the  presenting  part  and  in  about  97  per  cent,  it  is  the  head. 
Of  these,  the  vertex  presentation  is  the  one  most  commonly  seen 
and  is  the  one  in  which  the  child  is  most  easily  delivered.  Face 
presentations  are  very  rare,  occurring  in  only  a  fraction  of  1 
per  cent,  of  all  cases. 

In  addition  to  the  child's  presentation,  there  is  also  its 
position,  whicli  is  an  entirely  different  matter,  for  in  each  longi- 
tudinal presentation  the  presenting  part  may  occupy  any  one  of 
six  positions. 

By  position  is  meant  the  relation  of  some  arbitrarily  chosen 
point  on  the  presenting  part  of  the  fetus,  to  the  right  or  left 
side  of  the  mother,  and  to  the  front  (anterior),  side  (transverse) 
or  back  (posterior)  segment  of  that  side. 

Taking  these  up  in  turn,  w^e  find,  that  in  transverse  presenta- 
tions the  shoulder,  acromion  process,  is  the  point  on  the  baby's 
body  which  is  chosen,  to  give  the  four  possible  positions  their 
names. 


222  OBSTETRICAL  NURSING 

In  breech  presentations  the  sacrum  is  the  arbitrarily  chosen 
point. 

In  face  presentations  it  is  the  chin,  or  mentum,  while  in  ver- 
tex presentations  the  occiput  is  the  point  chosen. 

Presentation,  then,  describes  the  relation  of  the  long  axis  of 
the  entire  fetal  body  to  the  mother's  body,  while  position  de- 
scribes the  relation  between  the  baby 's  shoulder,  sacrum,  face  or 
occiput  to  the  mother's  pelvis. 

If  the  child  is  so  placed  in  the  uterus  that  the  head  is  the 
presenting  part;  the  neck  arched  with  chin  on  chest,  and  the 
occiput  directed  toward  the  mother's  left  side,  and  more  to  the 
front  than  to  the  side,  the  presentation  would  be  longitudinal, 
of  the  vertex  variety,  and  the  position  would  be  a  left-occipito- 
anterior.  The  arbitrarily  chosen  point  on  the  child's  body  (the 
occiput)  would  be  directed  toward  the  left,  anterior  segment  of 
the  mother's  pelvis.     This  is  the  situation  most  commonly  seen 


^^'^/VA^^^€^'P%rnLoi 


LOP 

Pig.  54. — Diagram  showing  the  six  possible  positions  in  a  vertex 
presentation. 

and  the  description  of  this  presentation  and  position  are  abbre- 
viated, by  taking  the  first  letter  of  each  word,  into  L.  0.  A. 

If  the  occiput  were  turned  directly  toward  the  mother's  left 
side,  neither  to  the  front  nor  the  back,  we  should  have  a  left- 
occipito-transverse,  L.  0.  T.,  and  if  it  were  directed  toward  the 
left  posterior  segment  of  the  pelvis  the  position  would  be  left- 
occipito-posterior,  or  L.  0.  P.  As  there  are  three  corresponding 
positions  on  the  right  side,  anterior,  transverse  and  posterior, 
there  are  six  possible  positions  for  tlie  child  to  occupy  in  the 
vertex,  or  occipital  presentations,  as  follows : 

Left-occipito-anterior,  abbreviated  to  L.O.A. 
Left-occipito-transverse,  abbreviated  to  L.O.T. 


PRESENTATION  AND  POSITION  OF  THE  FETUS     223 

Right-occipito-posterior,  abbreviated  to  L.O.P. 
Right-oceipito-anterior,  abbreviated  to  R.O.A. 
Right-oecipito-transverse,  abbreviated  to  R.O.T. 
Right-occipito-posterior,  abbreviated  to  R.O.P.    (Fig.  54.) 

Similarly  there  are  six  face  (Fig.  55)  and  six  breech  (Fig. 
56)  presentations.    Thus,  if  the  chin  (mentum)  is  resting  in  the 


WiT/r  'r^  )c^  JV-  ^"^ 

V  {^^"^    )  I    ^"^1  # 

V  w"'  "^  /  v  ^  ■",  /  y 

RMPX^  ^-^    -^LMP 

Fig.  55. — Diagram  showing  the  six  possible  positions  in  a  face  presentation. 

left  anterior  segment  of  the  mother's  pelvis,  the  position  would 
be  left-mento-anterior,  or  L.  M.  A.  If  the  breech  presents  and 
the  sacrum  is  in  that  relation  the  position  is  left-sacro-anterior, 
or  L.  S.  A. 

In  describing  the  transverse  presentations,  four  words,  in- 
stead of  three  are  used;  thus,  left-acromio-dorso-anterior,  or 
L.  A.  D.  A. 

There   are  but   four  varieties  of   transverse   presentations, 


RST/>-3tO  ^F-^\L51 


ftCLPXS^,   J     V    J^^\    ^p 


Fig.  56. — Diagram  showing  the  six  possible  positions  in  a  breech 
presentation. 

since  the  shoulder  is  either  anterior  or  posterior:  thus  left- 
acromio-dorso-anterior,  left-acromio-dorso-posterior  and  the 
two  corresponding  positions  on  the  right  side. 


224  OBSTETRICAL  NURSING 

During  the  last  two  to  four  weeks  of  pregnancy,  particularly 
among  the  primiparse,  the  top  of  the  fundus  settles  to  the  level 
which  it  reached  at  about  the  eighth  month,  and  the  lower  part 
of  the  abdomen  becomes  more  pendulous  than  formerly.  The 
patient  usually  breathes  much  more  comfortably  after  this 
change  in  contour  takes  place,  but,  at  the  same  time,  she  may 
have  cramps  in  her  legs  as  a  result  of  ^he  increased  pressure; 
more  difficulty  in  walking;  frequent  micturition  and  desire  to 
empty  her  bowels,  while  the  vaginal  discharge  may  be  consider- 
ably increased.  It  is  at  this  time  that  the  presenting  part  enters 
the  superior  strait  and  is  spoken  of  as  being  "engaged." 

The  time  at  which  engagement  takes  place  depends  upon 
three  factors:  Whether  the  patient  is  a  multipara  or  a  primi- 
para ;  the  size  and  normality  of  the  pelvis ;  the  size  and  position 
of  the  fetus.  It  is  often  helpful  to  the  obstetrician  in  planning 
for  the  delivery  to  know  whether  or  not  the  presenting  part  is 
engaged,  particularly  in  primiparaB. 

Although  in  primiparse  engagement  usually  occurs  about 
four  weeks  before  labor  begins,  it  does  not  normally  take  place 
in  multiparas  until  immediately  before  labor.  This  difference 
is  accounted  for  in  the  increased  tonicity  of  the  uterine  and  ab- 
dominal muscles  of  primiparous  women.  In  certain  abnormal- 
ities, or  marked  disproportion  between  the  diameters  of  the 
child's  head  and  mother's  pelvis,  engagement  may  not  take  place 
until  labor  is  well  advanced,  or  possibly  not  at  all. 

The  presentation  and  position  of  the  fetus  are  ascertained  by 
means  of  abdominal  palpation,  vaginal  examination,  rectal  ex- 
amination and  auscultation  of  the  fetal  heart. 

Palpation  of  the  child's  body  through  the  mother's  abdom- 
inal wall  is  possible  under  ordinary  conditions,  because  the  uter- 
ine and  abdominal  muscles  are  so  stretched  and  thinned  that 
the  various  parts  may  be  made  out  through  them.  But  it  is 
sometimes  difficult  in  hydramnios  and  is  practically  impossible  in 
very  fat  patients  or  in  the  case  of  a  ruptured  uterus  when  the 
fetal  outline  is  obscured  by  hemorrhage.  This  procedure  has 
been  practiced  only  during  comparatively  recent  years,  and  is 
regarded  by  many  obstetricians  as  one  of  the  most  important 
factors  in  reducing  the  frequency  of  puerperal  infections  and 


PRESENTATION  AND  POSITION  OF  THE  FETUS     225 

thus  in  decreasing  maternal  deaths.  The  explanation  is  that  in 
general  the  dangers  of  puerperal  infection  are  believed  to  in- 
crease in  direct  proportion  to  the  number  of  times  a  patient  is 
examined  vaginally ;  and  since  it  has  been  known  how  to  diag- 
nose the  child's  position  by  means  of  abdominal  i)alpation,  the 


Fig.    57. — First    maneuver    in    abdominal    palpation    to    disco\er    pixitioTi 

of  fetus. 

necessity'  for  vaginal  examinations  is  not  so  great  and  the}'  are 
accordingly  made  less  frequently. 

Rectal  examinations  may  also  be  regarded  as  a  factor  in  pre- 
venting infection,  for,  since  much  the  same  information  may 
be  obtained  by  means  of  them  as  by  vaginal  examinations,  after 
the  onset  of  labor,  they  often  replace  direct  exploration  of  the 
easily  infected  birth  canal. 


22C 


OBSTETRICAL  NURSING 


Abdominal  palpation,  as  usually  practiced,  consists  of  four 
maneuvers,  with  the  patient  lying  flat  and  squarely  on  her  back 
with  the  abdomen  exposed.  The  nurse  should  bear  in  mind  that 
successful  palpation  requires  even  pressure.  Cold  hands  applied 
to  the  abdomen  or  quick,  jabbing  motions  with  the  fingers  will 


Fig.   58. — Second  maneuver  in  abdominal  palpation. 

usually  stimulate  the  muscles  lying  beneath  them  to  contract, 
thus  somewhat  obscuring  the  outline  of  the  child.  Such  palpa- 
tion is  also  very  uncomfortable  for  the  patient;  but  firm,  even 
pressure,  started  gently,  with  warm  hands,  does  not  hurt. 

First  Maneuver.  The  purpose  of  the  first  maneuver  is  to 
ascertain  what  is  in  the  fundus ;  this  is  usually  either  the  head  or 
the  breech.    The  nurse  should  stand  facing  the  patient  and  gen- 


PRESENTATION  AND  POSITION  OF  THE  FETUS     227 

tly  apply  the  entire  tactile  surface  of  the  fingers  of  both  hands 
to  the  upper  part  of  the  abdomen,  on  opposite  sides  and  some- 
what curved  about  the  fundus.  (Fig.  57.)  In  this  way  the  out- 
line of  the  pole  of  the  fetus  which  occupies  the  fundus  may  be 
made  out.     If  the  head  is  uppermost,  it  will  be  felt  as  a  hard, 


Fig.   59. — Third   maneuver   in   abdominal   palpation. 

round  object  which  is  movable  or  hallottnhle  between  the  two 
hands,  and  if  the  breech,  it  will  be  felt  as  a  softer,  less  movable, 
less  regularly  shaped  body. 

Second  Maneuver.  Having  determined  whether  the  head  or 
the  breech  is  in  the  fundus,  the  next  step  is  to  locate  the  child's 
back  and  the  small  parts  in  their  relation  to  the  right  and  left 
sides  of  the  mother.    This  is  accomplished  by  slipping  the  hands 


228 


OBSTETRICAL  NURSING 


down  to  a  slightly  lower  position  on  the  sides  of  the  abdomen 
than  they  occupy  in  the  first  maneuver,  and  making  firm,  even 
pressure  with  the  entire  palmar  surface  of  both  hands.  The 
back  is  felt  as  a  smooth,  hard  surface  under  the  palm  and  fingers 
of  one  hand,  and  the  small  parts,  or  hands,  feet  and  knees,  as 


Fig.  60. — Fourth  maneuver  in  abdominal  palpation.     (This  series  of  pic- 
tures is  from   photographs  taken  at  Johns  Hopkins  Hospital.) 

irregular  knobs  or  lumps,  under  the  hand  on  the  opposite  side. 
(Fig.  58.) 

Third  Maneuver.  Unless  the  presenting  part  is  engaged,  the 
third  maneuver  virtually  amounts  to  a  confirmation  of  the  im- 
pression gained  by  the  first  maneuver,  by  showing  which  pole  is 
directed  toward  the  pelvis.    The  thumb  and  fingers  of  one  hand 


PRESENTATION  AND  POSITION  OF  THE  FETUS     229 


are  spread  as  widely  apart  as  possible,  applied  to  the  abdomen 
just  above  the  symphysis  and  then  brought  together  to  grasp 
the  part  of  the  fetus  which  lies  between  them.  If  not  engaged, 
the  head  will  be  felt  as  hard,  round  and  movable,  while  the 
breech  will  be  less  clearly  defined.     (Fig.  59.) 

Fourth  Maneuver.     The  fourth  maneuver  is  of  particular 


First  and  second   nnaneuvers 


Third  and  fourth   maneuvero 


Fig.    61. — Diagrams   showing   relation   of   nurse's   hands   to    fetus   in   the 
four  maneuvers   of   abdominal  palpation. 

value  after  the  presenting  part  has  become  engaged.  The  nurse 
faces  the  patient 's  feet  in  this  position,  and  directs  the  first  three 
fingers  of  each  hand  down  into  the  pelvis,  on  either  side  of  the 
fetus,  to  ascertain  whether  it  is  a  face  or  vertex  presentation,  by 
discovering  whether  chin  or  occiput  is  the  higher  cephalic  promi- 
nence in  the  mother's  pelvis.    (Fig.  60.)    If  it  is  a  vertex  presen- 


230 


OBSTETRICAL  NURSING 


tation,  the  neck  will  be  flexed,  with  the  chin  on  the  chest  and 
consequently  higher  in  the  pelvis  than  the  occiput.  The  nurse's 
fingers  of  one  hand  will  accordingly  come  in  contact  with  the 
chin  on  the  side  opposite  to  the  child's  back,  before  the  fingers 
of  the  other  hand  reach  the  occiput.  If,  however,  it  is  a  face 
presentation,  the  neck  will  be  bent  sharply  backward  and  the 
nurse's  fingers  will  feel  the  occiput  first,  and  on  the  same  side 
as  the  baby's  back.  This  maneuver  tells,  also,  how  far  into  the 
pelvic  the  presenting  part  has  descended. 


"Recto  vaginal 
'septum 


^T?ectuTn 


Fig.  62. — Diagram  showing  method  of  ascertaining  position  of  fetus 
by  means  of  rectal  examination.  Examining  finger  palpates  head  through 
recto-vaginal  septum. 

Vaginal  Examination.  The  information  obtained  by  va- 
ginal examination,  before  the  cervix  is  dilated,  is  rather  uncertain 
since  the  child's  presenting  part  must  be  palpated  through  the 
fornix.  But  after  complete,  or  even  partial  dilatation,  the  ex- 
ploring finger  is  able  to  feel  the  sagittal  suture  and  one  fonta- 
nelle,  in  a  vertex  presentation,  and  diagnose  the  position  by  dis- 
covering the  direction  of  the  suture  and  whether  it  is  the  anterior 
or  posterior  fontanelle  that  is  felt.     The  anterior  fontanelle,  it 


PRESENTATION  AND  POSITION  OF  THE  FETUS     231 

will  be  remembered,  is  relatively  large  and  four-sided,  while  the 
posterior  is  small  and  more  nearly  triangular  in  shape.  In  a 
face  presentation,  the  features  may  be  felt ;  in  a  breech  the  exam- 
ining finger  can  palpate  the  buttocks  and  genital  crease. 

Because  of  the  possible  danger  of  introducing  infective  ma- 
terial into  the  birth  canal,  the  tendency  is  to  make  fewer  and 
fewer  vaginal  examinations,  and  then  only  after  the  most  pains- 
taking preparation  which  will  be  described  presently.  Needless 
to  state,  vaginal  examinations  are  not  within  the  province  of  the 
nurse. 

Rectal  Examinations.  More  and  more  frequently  rectal  ex- 
aminations are  being  employed  to  obtain  information  about  the 
child's  position,  as  the  examining  finger  is  able  to  feel  the  sur- 
face of  the  presenting  part  through  the  recto-vaginal  septum, 
after  the  cervix  is  dilated,  and  there  is  no  danger  of  infecting  the 
birth  canal  while  so  doing.  For  this  reason  nurses  are  frequently 
taught  to  make  rectal  examinations,  thereby  increasing  the  value 
of  their  assistance  to  the  doctor  in  w^atching  the  progress  of 
labor.     (Fig.  62.) 

Auscultation  of  the  fetal  heart  is  valuable  in  confirming  the 
diagnosis  of  presentation  and  position  which  has  been  made  by 
palpation.  In  vertex  and  breech  presentations  the  heartbeat  is 
best  heard  through  the  baby 's  back  and  in  face  presentations  it 
is  transmitted  throu^'h  the  chest,  which  presents  a  convex  sur- 
face in  this  case  and  fits  into  the  curve  of  the  uterine  wall.  In 
anterior  vertex  presentations  the  heart  is  heard  a  little  to  the 
side  and  below  the  umbilicus ;  in  transverse,  further  to  the  side.^ 
and  in  posterior,  well  toward  the  back. 


CHAPTER  XI 

SYMPTOMS,   COURSE  AND  MECHANISM  OF  NORMAL 

LABOR 

Labor  may  be  defined  as  the  process  by  means  of  which  the 
product  of  conception  is  separated  and  expelled  from  the 
mother's  body.  It  ordinarily  occurs  about  280  days  from  the 
beginning  of  the  last  menstrual  period.     (See  p.  93.) 

The  cause  of  labor  is  not  known.  Many  theories  have  been 
advanced  to  explain  why  the  uterine  contractions,  which  have 
occurred  painlessly  throughout  pregnancy,  and  without  expul- 
sive force,  finally  become  painful  at  the  end  of  the  tenth  month 
and  so  changed  in  character  as  to  extrude  the  uterine  contents; 
but  as  yet,  none  is  wholly  satisfactory  nor  generally  accepted. 
Nor  is  it  known  why  some  labors  are  premature  and  some  delayed. 

The  onset  of  labor  is  usually  marked  by  the  patient's  becom- 
ing conscious  of  the  uterine  contractions  through  dragging  pains 
which  may  be  felt  first  in  the  back  and  then  in  the  lower  part 
of  the  abdomen  and  the  thighs.  At  first  the  pains  are  feeble 
and  infrequent,  but  they  gradually  grow  more  severe  and  more 
frequent.  Intestinal  colic  is  sometimes  mistaken  for  labor  pains, 
but  when  the  paroxysms  are  rhythmical  and  the  uterus  is  felt, 
through  the  abdominal  wall,  to  grow  hard  as  the  pain  increases 
and  soft  as  it  subsides,  there  can  be  no  doubt  but  that  the  pa- 
tient is  in  labor.  The  first  signs  of  labor  may  be  a  gush  of  am- 
niotic fluid,  caused  by  the  rupture  of  the  membranes,  or  ^of 
blood,  but  these  are  not  typical. 

For  purposes  of  convenience,  labor  is  usually  described  as 
consisting  of  three  periods  or  stages.  The  first  stage  begins  with 
the  onset  of  labor  and  lasts  until  the  cervix  is  completely  dilated ; 
the  second  stage  begins  with  the  complete  dilatation  of  the  cervix 
and  lasts  until  the  child  is  born ;  the  third  stage  begins  with  the 
birth  of  the  child  and  lasts  until  the  placenta  is  expelled. 

5232 


SYMPTOMS,  COURSE  AND  MECHANISM  OF  LABOR     233 

The  entire  duration  of  labor  may  vary  from  a  few  moments, 
comprising  a  few  pains,  to  several  days  of  severe  and  exhausting 
pain,  but  the  average  length  of  the  first  labor  is  18  hours  and  of 
subsequent  labors  about  12  hours,  divided  respectively  into  the 
three  periods  as  follows : 


1st  stage. 

2nd  stage. 

3rd  stage. 

Total. 

Primipara 

16  hours 

1%  hours 

15  minutes 

18  hours. 

Multipara 

11  liours 

45    minutes 

15  minutes 

12  hours. 

The  longer  labor  in  primiparous  women  is  due  to  the  greater 
tone,  and  thus  the  greater  resistance  offered  by  the  muscles  of 
the  cervix  and  perineum.  Elderly  primiparae  are  likely  to  have 
longer  labors  than  young  primipara. 

First  Stage.  This  is  frequently  called  the  stage  of  dilata- 
tion. During  this  period  the  contractions  of  the  uterine  muscles 
make  pressure  upon  the  amniotic  sac  of  fluid,  forcing  it  gradu- 
ally down  and  into  the  cervix  as  a  water  wedge,  widening  the 
internal  os  first,  then  the  external  os,.  until  the  entire  canal  is 
fully  dilated  (thinned  out)  ;  shortened  to  about  one-half  inch 
in  length  and  finally  obliterated  so  that  it  is  uninterruptedly 
continuous  with  the  lower  uterine  segment.  (Figs.  63,  G4,  65,  66.) 

The  first  stage  pains  begin  by  being  mild  and  occurring  at 
intervals  of  from  15  to  30  minutes,  but  they  gradually  increase 
in  frequenc,y  and  intensity  until  at  the  end  of  14  to  16  hours  they 
are  very  severe  and  recur  every  three  or  four  minutes,  each  pain 
lasting  about  one  minute.  The  pains  begin  in  the  back,  pass 
slowly  forward  to  the  abdomen  and  down  into  the  thighs. 

The  patient  is  entirely  comfortable,  as  a  rule,  between  pains 
and  until  they  become  very  frequent  will  usually  feel  able,  in 
fact  prefer,  to  be  up  and  about,  but  if  she  is  on  her  feet  when 
a  contraction  begins  she  will  usually  seek  relief  by  assuming  a 
characteristic  leaning  position  (Fig.  67)  or  by  sitting  down, 
until  the  pain  subsides.  As  dilatation  advances,  the  patient  has 
an  increasing,  sometimes  persistent,  desire  to  empty  the  bowels 
and  bladder  because  of  encroachment  upon  these  two  organs  by 
the  descending  head.  She  may  vomit,  also,  when  the  cervix  be- 
comes nearly  or  quite  dilated. 

In  the  course  of  this  stretching  process,  the  cervix  sustains 


234 


OBSTETRICAL  NURSING 


SYMPTOMS,  COURSE  AND  MECHANISM  OP  LABOR      235 

many  tiny  lesions,  from  which  blood  oozes  and  tinges  the  vaginal 
discharge.  This  blood-stained  secretion  is  often  called  the 
"show"  and  usually  appears  toward  the  end  of  the  first  stage. 

As  a  rule,  when  the  cervix  is  fully  dilated  the  membranes 
rupture  and  there  is  a  sudden  gush  of  that  part  of  the  fluid 
which  was  below  the  fetus  in  the  amniotic  sac,  but  the  rupture 


Fig.  67. — Characteristic  position  which  patient  often  assumes  during  pains 

in  first  stage. 

of  the  membranes  does  not  necessarily  mark  the  end  of  the  first 
stage.  In  some  instances  they  rupture  before  the  cervix  is  fully 
dilated ;  in  others,  though  not  often,  before  the  patient  goes  into 
labor,  thus  producing  what  is  known  as  a  "dry"  labor. 

The  abdominal  muscles  do  not  contract  very  forcibly  during 
the  first  stage,  the  expulsive  force  in  this  period  coming  almost 
entirely  from  the  uterine  contractions.  The  patient's  cries  at 
this  time  are  sharp  and  complaining  in  contrast  to  the  groans 
and  grunts  which  accompany  the  second  stage. 


236 


OBSTETRICAL  NURSING 


Complete  dilatation  of  the  cervix  marks  the  termination  of 
the  first  stage. 

Second  Stage.  The  second  stage  is  sometimes  called  the 
stage  of  descent,  or  expulsion,  of  the  fetus.  The  patient  should 
and  is  usually  quite  willing  to  be  in  bed  throughout  the  second 
stage,  during  which  she  should  not  be  left  alone.  The  pains  are 
now  regular,  occurring  at  intervals  of  about  two  minutes  from 
the  beginning  of  one  to  the  beginning  of  the  pain  following,  and 
as  the  contractions  last  about  one  minute  and  are  excruciatingly 


Fig.    68. — Diagram   indicating   the  rotation   and   pivoting   of   baby's   head 

during  birth. 

painful,  the  patient  has  very  little  respite  from  her  suffering. 
Her  face  is  flushed  and  she  may  perspire  freely. 

The  abdominal  and  respiratory  muscles  are  brought  into  ac- 
tive use  during  the  second  stage,  contracting  simultaneously 
with  the  uterine  muscles  and  increasing  their  expulsive  force. 
These  are  apparently  controlled  by  the  patient 's  will  at  first,  and 
she  is  able  somewhat  to  increase  their  power  by  taking  a  deep 
breath,  closing  her  lips,  bracing  her  feet,  pulling  against  some- 
thing with  her  hands,  straining  with  all  her  might  and  ''bear, 
ing  down."  Finally,  however,  the  whole  bearing  down  process 
becomes  involuntary,  is  accompanied  by  intense  pain  and  the 


SYMPTOMS,  COURSE  AND  MECHANISM  OF  LABOR    237 

deep  grunting  sound,  which  is  characteristic  of  the  well-advanced 
second  stage.  Under  normal  conditions,  the  child  descends  a  lit- 
tle farther  into  the  pelvis  with  each  contraction,  and  finally  the 
presenting  part  begins  to  distend  the  perineum  and  to  separate 
the  labia  advancing  at  the  height  of  each  pain  and  slipping 
back  a  little  as  it  subsides. 


Fig.  69. — Anterior  shoulder  being'  slipped  from  under  symphysis  to 
facilitate   birth   of   posterior   shoulder. 

The  baby  descends  into  and  through  the  mother's  pelvis  by 
means  of  a  series  of  twisting  and  curving  motions,  accommodat- 
ing the  long  axes  of  its  head  to  the  long  diameters  of  the  pelvis. 
The  head  being  somewhat  compressible  and  mouldable,  because 
of  imperfect  ossification,  is  capable  of  a  good  deal  of  accommo- 
dation to  the  mother's  pelvis. 


238  OBSTETRICAL  NURSING 

The  mechanism  of  labor,  therefore,  is  virtually  a  series  of 
adaptations  of  the  size,  shape  and  mouldability  of  the  baby's 
head  to  the  size  and  shape  of  the  mother's  pelvis.  If  the  head 
passes  through  the  inlet  satisfactorily,  the  rest  of  the  labor  will 
usually  be  accomplished  with  comparative  safety.  But  a 
marked  disproportion  between  the  diameters  of  the  head  and  pel- 


Fig.    70. — Delivery    of    posterior    shoulder. 

vis  may  interfere  with  the  engagement  or  descent  of  the  head 
and  produce  a  serious  complication. 

The  long  diameter  of  the  head  must  first  conform  to  one  of 
the  long  diameters  of  the  inlet,  usually  oblique,  and  then  turn 
so  that  the  length  of  the  head  is  lying  antero-posterior  in  con- 
formity to  the  long  diameter  of  the  outlet  through  which  it  next 
passes.  As  the  head  descends  and  rotates  it  also  describes  an 
arc  because  the  posterior  wall  of  the  pelvis,  consisting  of  the 
sacrum  and  coccyx,  is  about  three  times  as  deep  as  the  anterior 


SYMPTOMS,  COURSE  AND  MECHANISM  OF  LABOR    239 

wall  formed  by  the  symphysis.  That  part  of  the  baby's  head 
which  passes  down  the  posterior  wall  of  the  pelvis  must  therefore 
travel  three  times  as  far  in  a  given  time  a?  the  part  which  simply 
slips  under  the  short  symphysis  pubis. 

In  a  vertex  presentation,  left-occipito-anterior  position,  while 
the  occiput  passes  under  the  symphysis  and  appears  at  the  dis- 
tending vaginal  outlet,  the  face  passes  down  the  posterior  wall 
and  along  the  floor  of  the  pelvis.  As  pressure  is  exerted  by  the 
rapidly  succeeding  contractions,  the  head  pivots  about  the  pubis, 
thus  extending  the  neck  and  pushing  the  face  farther  downward 


Initial  point     \K^\ 

of  reparation   ^^^^^^;^  \ 


Duncan 


InlUal 
of  £>epafat 


Schult:ie 


Fig.  71. 


-Diagrams  showing  Duncan  and  Schultze  mechanisms  of  placental 
separation. 


and  forward.  After  emergence  of  the  back  and  top  of  the  head 
below  the  symphysis,  the  forehead  appears  over  the  posterior 
margin  of  the  vagina,  then  the  brow,  eyes,  nose,  mouth  and  chin 
in  turn,  and  the  entire  head  is  born.  (Fig.  68.)  The  baby's 
head  then  drops  forward,  in  relation  to  its  own  body,  with  its 
face  toward  the  mother's  rectum  and  the  occiput  in  front  of  the 
pubis,  but  soon  the  occiput  rotates  toward  the  mother's  left  side, 
resuming  the  relation  that  it  bore  to  the  inner  aspect  of  her 
pelvis  before  expulsion.     The  undelivered  shoulders  are  now  an- 


240 


OBSTETRICAL  NURSING 


tero-posterior,  one  under  the  pubis  and  the  other  resting  on  the 
perineum.  (Fig.  69.)  The  lower,  or  posterior  shoulder  is  born 
first  (Fig.  70),  followed  quickly  by  the  anterior  shoulder  and 
the  rest  of  the  body,  and  the  amniotic  fluid  which  was  behind 
the  child's  body.    Thus  is  the  second  stage  completed. 


Fig.  72. — Longitudinal  section  through  uterus  showing  thinness  of 
uterine  wall  before  expulsion  of  fetus,  contrasting  sharply  with  thickened 
wall  in  Fig.  73.  (From  photograph  of  specimen,  to  which  twin  placentae 
are  still  adherent  in  upper  segment,  in  the  obstetrical  laboratory,  Johns 
Hopkins  Hospital.) 

Third,  Stage.  The  third  stage,  sometimes  termed  the 
placental  stage,  is  that  period  following  the  birth  of  the  child, 
during  which  the  placenta  is  delivered.  For  a  few  moments 
after  the  baby  is  born  the  tired  mother  lies  quietly  and  free  from 
pain,  as  there  is  a  temporary  cessation  of  the  uterine  contrac- 


aYMPTOMS,  COimSE  AND  MECHANISM  OP  LABOR    241 


tions,  and  she  often  sleeps  as  a  result  of  the  anesthetic  given 
during  the  second  stage. 

The  uterus  has  greatly  decreased  in  size,  the  fundus  now 
lying  below  the  umbilicus  where  it  may  be  felt  as  a  firm,  solid 
mass.  The  uterine  contractions  are  resumed  in  the  course  of  a 
few  moments  and  as  they  persist,  the  uterus  grows  smaller, 
thereby  greatly  decreasing  the  area 
of  placental  attachment.  As  the 
placenta  is  non-contractile  it  can- 
not accommodate  itself  to  this 
decreased  area  of  attachment,  and 
so  is  literally  squeezed  from  its 
moorings.  It  is  then  gradually 
forced  down  into  the  lower  uterine 
segment  where  it  may  be  located  by 
the  distension  of  the  abdominal 
wall  which  it  produces  just  abovd 
the  symphysis.  After  the  separa- 
tion of  the  placenta  is  complete  the 
uterus  rises  in  the  abdominal 
cavity  until  the  fundus  is  felt 
above  the  umbilicus.  The  placenta, 
finally,  may  be  completely  expelled 
spontaneously,  or  expressed  by 
slight  pressure  made  upon  the 
fundus  by  the  accoucheur. 

The  placental  detachment  may 
begin  at  the  centre,  the  area  of 
separation  spreading  to  the  margin,  or  the  detachment  may 
start  at  the  margin  of  the  placenta  and  extend  toward  the  centre. 
Either  is  normal.  These  two  modes  of  placental  separation  are 
named  the  Schultze  and  the  Duncan,  respectively,  from  the  men 
who  first  described  them.     (Fig.  71.) 

In  the  Schultze  mechanism,  which  occurs  most  frequently, 
the  separating  process  begins  at  the  centre  of  the  placenta  and 
the  glistening  fetal  surface  appears  at  the  vaginal  outlet.  In 
this  case  there  is  practically  no  bleeding  during  the  third  stage 


Fig.  73. — Longitudinal  sec- 
tion througli  uterus,  immedi- 
ately after  labor,  showing 
marked  thickening  of  wall  as  a 
result  of  muscular  contraction. 
(From  i)hotogra])h  of  specimen 
in  the  obstetrical  laboratory, 
Johns  Hopkins  Hospital.) 


242  OBSTETRICAL  NURSING 

as  the  inverted  placenta  blocks  the  vagina  and  holds  back  the 
blood. 

In  Duncan 's  mechanism  the  detachment  begins  at  the  margin, 
the  placenta  rolls  upon  itself  and  presents  at  the  outlet  by  its 
roughened  maternal  surface  and  there  is  usually  slight  but  con- 
tinuous bleeding  from  the  time  the  separation  begins.  When 
the  placenta  is  delivered,  the  collapsed  membranes  trail  after  it 
like  a  tapering  cord.  A  good  deal  of  blood  is  lost  at  the  time 
of  the  placental  expulsion  and  immediately  afterwards,  but  this 
profuse  bleeding  usually  subsides  in  a  few  moments.  Although 
the  loss  of  blood  may  be  as  much  as  500  cubic  centimetres  with- 
out its  being  regarded  as  serious,  the  average  amount  is  about 
350  cubic  centimetres. 

The  patient  has  been  through  a  severe  ordeal  and  at  the  end 
of  the  third  stage  of  labor  she  is  usually  tired  out  and  cold. 


CHAPTER  XII 
THE  NURSE'S  DUTIES  DURING  LABOR 

The  extent  of  the  nurse's  helpfulness  during  labor,  both  to 
the  patient  and  to  the  doctor,  will  depend  very  largely  upon 
the  intelligence  with  which  she  grasps  what  is  taking  place  and 
upon  her  own  attitude,  as  an  individual,  toward  the  patient  and 
the  miraculous  event  which  approaches.  Important  as  is  the 
preparation  of  the  room  and  dressings,  this  other  factor  is  al- 
most equally  influential. 

It  will  be  wiser,  therefore,  for  the  nurse  to  try  to  picture 
the  process  of  labor  in  each  instance,  and  to  be  guided  by  a  few 
broad  principles  that  apply  to  all  cases  under  all  conditions, 
rather  than  to  try  to  memorize  the  details  of  her  duties  and  of 
the  desirable  equipment  and  preparation. 

The  process  of  labor  we  have  just  described. 

As  to  the  general  principles :  If  there  is  any  time  in  a  nurse 's 
career  when  she  should  give  scrupulous  attention  to  establishing 
and  maintaining  asepsis,  it  is  during  labor,  for  the  patient 's  life 
may,  and  often  does  depend  upon  it.  If  there  is  any  time  when 
she  should  be  watchful  for  developments  and  for  symptoms  of 
complications,  it  is  during  labor,  for  again  the  patient's  life  may 
depend  upon  this. 

Her  powers  of  adaptability  to  doctor,  patient  and  surround- 
ings may  be  severely  tried,  for  though  they  all  may  be  infinitely 
varied,  the  nurse  must  invariably  be  clear-headed  and  efficient 
and  the  adequacy  of  her  service  must  never  fail. 

The  sympathetic  insight,  which  should  constantly  underlie 
the  work  of  the  obstetrical  nurse,  will  be  needed  at  this  crucial 
time  of  labor  in  the  fullest  and  finest  and  completest  sense.  This 
is  almost  her  test  as  a  nurse  and  as  a  womanly  woman,  for  she 
needs  to  be  both,  supremely. 

Perhaps  she  had  better  imagine  for  a  moment  what  this 
occurrence,  that  we  baldly  term  labor,  may  mean  to  the  patient 

243 


244  OBSTETRICAL  NURSING 

and  look  at  it  as  nearly  as  possible  from  the  standpoint  of  the 
patient  herself.  It  is  one  of  the  most  stirring  and  momentous 
experiences  of  her  life,  particularly  if  the  expected  baby  is  her 
first  child.  She  is  about  to  realize  the  sweetest  and  tenderest 
of  dreams — that  of  motherhood — cherished  throughout  nine  long 
months.  She  is  also  approaching  a  period  of  excruciating  pain, 
and  knows  it,  with  her  eyes  wide  open  to  the  possibility  of  not 
surviving  it ;  and  an  event  so  amazing  in  its  mystery  and  wonder 
that  to  only  the  most  stolid  can  it  fail  to  be  a  deeply  emotional 
experience. 

And  so,  the  young  woman,  to  whom  we  refer  so  impersonally 
as  "the  patient,"  is  an  intensely  personal  being  at  this  time, 
experiencing  a  number  of  the  most  poignant  of  the  human  emo- 
tions: awe,  expectancy,  doubt,  uncertainty,  dread  and  in  some 
cases  fear  amounting  almost  to  terror.  And  through  it  all  her 
body  is  being  racked  and  exhausted  with  pain  that  grows  harder 
and  harder  to  bear. 

It  is  known  that  the  ravaging  effects  of  pain,  coupled  wiih 
great  emotional  stress,  such  as  fear,  worry,  doubt,  anger  or 
apprehension,  upon  the  physical  well-being  of  surgical  patients, 
is  such  that  death  itself  may  be  caused  by  excessive  fear  and 
suffering.  Accordingly,  many  careful  surgeons  take  elaborate 
precautions  to  tranquillize  a  patient  who  is  about  to  be  operated 
upon,  if  for  no  other  reason  than  to  increase  his  chance  for 
recovery. 

There  can  be  no  doubt  that  nervous  and  emotional  disturb- 
ances are  detrimental  to  the  physical  well-being  of  the  patient 
in  labor,  also,  and  this  fact  alone  is  enough  to  warrant  an  effort 
to  avert  them.  If  the  nurse  appreciates  the  significance  of  the 
emotional  influence  and  shapes  her  attitude  and  conduct  accord- 
ingly, she  will  thereby  help  to  increase  the  ease  and  safety  of 
the  actual  delivery.  Just  what  that  attitude  shall  be,  no  one 
can  say,  for  it  must  be  developed,  in  each  case,  in  such  a  way 
as  to  win  the  confidence  and  meet  the  needs  of  that  particular 
patient. 

But  in  all  cases  the  nurse  should  impress  her  patient  with 
her  sincere  sympathy  and  appreciation  of  the  fact  that  she,  the 
patient,  is  going  through  a  difficult  time.     Through  it  all  the 


THE  NURSE'S  DUTIES  DURING  LABOR  245 

nurse  must  be  cheerful,  encouraging  and  optimistic  ;  very  gentle ; 
very  calm  and  reassuring  in  all  that  she  does  in  preparing  for 
the  delivery.  She  must  steadily  increase  the  patient's  realiza- 
tion of  the  part  which  she  herself  must  play  in  the  effort  which 
is  being  made  to  carry  the  event  through  to  a  happy  issue. 

The  occasion  need  not,  should  not,  be  a  mournful  one  but  it 
is  often  a  very  sacred  one  to  the  patient,  and  the  nurse  should 
be  dignified,  almost  reverential  in  her  bearing. 

If  the  patient  feels  secure  in  the  belief  that  her  ordeal  is 
not  being  taken  lightly ;  that  it  is  being  regarded  seriously,  as  it 
merits,  and  that  every  known  precaution  is  being  taken,  and 
taken  confidently,  to  safeguard  her  and  her  baby's  welfare,  her 
actual  physical  condition  will  be  favorably  affected  by  the  con- 
dition of  mind  thus  produced.  And  her  patience  and  courage 
will  often  be  strengthened  if  the  nurse  will  explain,  from  time 
to  time,  the  cause  of  certain  conditions  that  normally  arise,  and 
which  otherwise  might  give  her  alarm.  It  is  the  mysterious 
events,  the  unexpected  and  unexplained  that  so  often  terrify. 

This  giving  of  comfort  and  strength  to  the  variety  of  tem- 
peraments and  mentalities  which  the  nurse  meets  among  her 
patients  will  involve  a  very  sensitive  adjustment  of  manner  on 
her  part,  but  it  is  one  aspect  of  her  duty,  none  the  less,  and  one 
which  will  give  her  great  satisfaction. 

FIRST  STAGE 

Happily,  the  onset  of  labor  is  usually  gradual,  as  has  been 
described,  and  there  is  accordingly  ample  time  during  the  first 
stage  for  deliberate  and  unhurried  preparation  for  the  birth  of 
the  baby.  The  character  of  the  preparation  and  of  the  nurse's 
assistance  will  vary  greatly  according  to  the  wishes  of  the  at- 
tending doctor ;  the  duration  of  labor ;  the  circumstances  and  con- 
dition of  the  patient,  and  whether  she  is  at  home  or  in  a  hospital. 

It  is  a  fairly  general  routine,  at  present,  both  in  hospitals 
and  in  the  home,  to  give  the  patient  a  soap-suds  enema  and  a 
shower  or  sponge  bath,  at  the  onset  of  labor;  to  braid  her  hair 
in  two  braids  and  dress  her  in  freshly  laundered  stockings  and 
nightgown  and  a  dressing  go^vn.  The  enema  is  given  to  empty 
the  rectum  of  material  which  might  be  expelled  during  labor 


246  OBSTETRICAL  NURSING 

and  contaminate  the  field.  For  this  reason,  enemata  are  often 
given  until  the  fluid  returns  clear,  virtually  irrigating  the 
rectum,  and  are  repeated  every  six  or  eight  hours  during  the 
first  stage.  The  enema  should  be  given  to  the  patient  in  bed 
and  expelled  into  a  bed-pan,  as  it  is  not  wise  for  her  to  use  the 
toilet  after  labor  has  begun.  Sometimes  the  vulva  and  perineal 
region  are  shaved  and  scrubbed  at  the  onset  of  labor,  either  be- 
fore or  immediately  after  the  bath  and  enema.  But  the  time  and 
sequence  of  the  different  steps  in  the  preparation  for  labor  are 
governed  entirely  bj^  the  wishes  of  the  individual  doctor,  to 
which  the  nurse  may  very  easily  adjust  herself. 

The  patient  should  be  given  a  bed-pan  and  encouraged  to 
void  every  four  hours.  If  she  is  unable  to  do  so,  and  the  bladder 
becomes  distended,  the  doctor  will  usually  wish  to  have  her 
catheterized,  and  with  a  rubber  catheter.  This  distension  is  not 
uncommon,  and  in  extreme  cases  the  bladder  may  reach  to  the 
umbilicus.  The  nurse  should  therefore  observe  the  amount  of 
urine  which  the  patient  voids  and  also  watch  the  lower  abdomen 
for  bladder  distension,  which  may  be  observed  easily,  excepting 
in  very  fat  patients. 

The  seriousness  of  a  distended  bladder  lies  in  the  fact  that 
it  may  markedly  retard  labor,  partly  by  interfering  with  the 
descent  of  the  baby's  head  and  partly  through  reflex  inhibition 
of  the  uterine  contractions.  The  prevention  of  a  distended 
bladder  during  labor,  therefore,  is  of  considerable  importance. 

As  the  pains  are  infrequent  and  not  severe  at  first,  the  patient 
will  usually  prefer  to  be  up  and  about,  most  of  the  time  during 
the  first  stage,  when  it  occurs  in  the  daytime,  and  many  doctors 
think  it  important  that  she  should  be.  They  feel  that  patients 
tend  to  stay  in  bed  too  much  during  the  first  stage,  since  being 
on  their  feet  would  really  promote  their  comfort  and  also  have 
a  tendency  to  make  the  pains  more  regular  and  efficient.  But, 
on  the  other  hand,  the  patient  must  be  cautioned  against  tiring 
herself,  and  should,  therefore,  lie  down  often  enough  and  long 
enough  to  avert  fatigue.  When  labor  begins  at  night,  it  is  well 
to  advise  the  patient  to  stay  in  bed  and  to  sleep  as  much  as 
possible  until  morning.  Even  though  her  sleep  be  disturbed 
and  broken  by  the  labor  pains,  she  will  be  much  less  tired  in 
the  morning  than  if  she  had  gotten  up  and  had  no  sleep  at  all. 


THE  NURSE  S  DUTIES  DURliNG  LABOR  247 

The  patient  should  also  be  advised  against  trying  to  hasten 
labor  by  bearing  down  during  first  stage  pains,  since  the  only 
result  at  this  time  will  be  to  waste  her  strength  which  will  be 
needed  later.  This  is  one  of  the  points  that  the  nurse  will  do 
well  to  explain;  that  no  voluntary  effort  on  the  patient's  part, 
during  the  first  stage,  will  advance  labor  and  if  she  tires  herself 
by  making  such  efforts  before  the  second  stage  pains  begin  she 
will  not  be  able  to  use  them  as  effectively  as  she  would  were  she 
in  a  rested  condition. 

Bearing  in  mind  the  importance  of  conserving  all  of  her 
forces,  it  is  usually  advisable  for  a  patient  in  labor  to  have  no 
visitors,  particularly  the  type  of  person  who  would  be  likely  to 
offer  advice  and  gratuitous  information. 

She  should  drink  water  freely  and  take  some  kind  of  light 
nourishment  about  every  four  hours.  As  pain  of  any  kind  tends 
to  retard  digestion,  the  diet  during  labor  is  usually  restricted 
to  fluids,  such  as  broths,  weak  tea  or  coffee  and  sometimes  milk  or 
cocoa;  while  occasionally  crackers  and  crisp  toast  are  allowed. 
Whatever  nourishment  is  given  must  be  very  light  because  of 
the  probability  of  the  patient's  vomiting  and  the  possibility  of 
her  having  to  be  given  complete  anesthesia  before  the  termina- 
tion of  labor. 

The  maternal  temperature,  pulse  and  respirations  should 
be  taken  every  two  or  four  hours  and  the  fetal  heart  rate  from 
every  hour  to  every  two  hours,  according  to  the  wishes  of  the 
doctor. 

The  time  at  which  the  nurse  should  call  the  doctor  is  the 
subject  of  considerable  discussion.  Doctors  never  want  to  be 
called  too  late,  neither  do  they  wish  to  be  called  unnecessarily 
early,  though  they  prefer  to  have  the  nurse  err  on  that  side, 
if  at  all.  On  general  principles  the  doctor  should  be  notified 
as  soon  as  the  patient  goes  into  labor,  in  order  that  he  may  make 
his  various  plans  with  the  pending  delivery  in  mind.  But  if 
the  nurse  remembers  that  in  primiparae  the  first  stage  of  labor 
usually  lasts  about  sixteen  hours  and  in  multiparae  about  eleven 
hours,  she  will  realize  that  if  the  pains  begin  between  the  hours 
of  eleven  p.m.  and  seven  a.m.,  and  are  of  average  character,  mild 
and  infrequent,  she  is  not  warranted  in  disturbing  the  doctor's 
much  needed  sleep,  unless  he  has  explicitly  requested  her  to  do 


248  OBSTETRICAL  NHRSING 

so.  But  under  average  conditions  he  should  be  notified  by  seven 
0  'clock  in  the  morning  that  the  patient  is  in  labor ;  at  what  hour 
the  pains  began;  their  character  and  frequency  at  the  time  of 
the  report;  the  patient's  temperature,  pulse  and  respirations 
and  general  condition  and  the  fetal  heart  rate. 

During  the  early  hours  of  the  first  stage  the  nurse  should 
begin  to  arrange  the  room  and  bed  for  delivery.  She  will  need 
two,  or  preferably,  three  tables,  though  the  top  of  a  bureau  may 
be  used  in  place  of  one  table.  A  washstand  or  the  bathroom 
should  be  equipped  for  the  doctor  with  soap ;  two  sterile  brushes ; 
nail  scissors  or  clippers  and  file  or  orange  stick;  hot  water; 
alcohol  and  a  solution  of  bichlorid  1-1000,  biniodid  1-5000,  lysol 
2  per  cent,  or  any  solution  that  he  may  wish ;  sterile  gloves  and 
sterile  vaseline  or  albolene  to  lubricate  his  hands.  In  short,  an 
equipment  which  will  enable  him  to  prepare  his  hands  exactly 
as  he  would  for  performing  a  major  operation. 

A  large  receptacle  of  water  may  be  boiled,  covered  and  set 
aside  to  cool ;  a  boiler  or  large  kettle  placed  in  readiness  for  boil- 
ing instruments  or  other  appliances  that  the  doctor  may  bring; 
the  room  may  be  given  a  final  cleaning  :  floor  wiped  up,  furniture 
and  all  small  articles  wiped  with  a  damp  cloth;  the  unopened 
packages  of  dressings,  sterile  douche  pan,  irrigation-bag  and 
basins  may  be  placed  on  the  tables,  ready  to  be  opened  when 
needed,  together  with  the  other  articles  which  have  been  pre- 
pared. 

In  preparing  the  bed  in  a  patient's  home,  it  is  practically 
always  advisable  to  make  it  firm  by  slipping  a  board,  or  the 
leaves  from  a  dining-table,  between  the  mattress  and  springs. 
The  bed  should  be  made  up  with  three  freshly  laundered  sheets, 
the  entire  mattress  being  protected  by  means  of  a  rubber  placed 
under  the  lower  sheet ;  next  a  rubber  draw  sheet,  covered  by 
one  of  muslin,  while  the  top  sheet,  light  blanket  and  counterpane 
should  be  left  free  at  the  foot.  A  flat  hair  pillow  is  better  than 
one  of  feathers. 

If  the  doctor  wishes  to  make  a  vaginal  examination,  it  de- 
volves upon  the  nurse  to  prepare  the  patient  with  the  most 
scrupulous  care,  as  it  is  by  means  of  vaginal  examinations,  made 
without  careful  preparation,  that  so  many  parturient  women 


THE  NURSE'S  DUTIES  DURING  LABOR  249 

are  infected.  In  fact,  even  the  most  conscientious  preparation 
sometimes  seems  to  be  an  inadequate  safegcuard,  for  infection 
has  been  known  to  follow  in  its  wake.  For  this  reason,  some 
obstetricians  prefer  to  make  no  vaginal  examination  during 
labor,  when  previous  inspection  has  indicated  that  the  case  is 
normal,  depending  rather  upon  rectal  examinations  for  guiding 
information. 

The  patient  should  be  placed  in  bed,  on  a  douche  pan,  with 
knees  flexed  and  well  separated;  gown  tucked  up  under  her 
arms;  draped  with  a  sheet  or  the  bedding  folded  down  to  her 
knees  according  to  the  extent  of  the  area  to  be  prepared;  and 
the  articles  needed  for  the  preparation  arranged  on  a  table  at 
the  bedside.  The  nurse  should  trim  her  nails,  scrub  her  hands 
with  soap  and  hot  water;  shave  the  vulva,  supra-pubic  region 
and  inner  surface  of  the  thighs  and  rinse  with  sterile  water.  In 
shaving  the  vulva,  the  strokes  should  be  from  above  downward, 
greatest  care  being  taken  not  to  allow  hair,  soap  or  water  to 
enter  the  vaginal  opening.  She  should  then  scrub  her  hands 
vigorously  for  three  minutes,  scrubbing  about  the  nails  with 
especial  thoroughness.  Some  obstetricians  have  the  entire  area 
from  the  umbilicus  to  the  knees  prepared  as  for  an  operation, 
while  others  prepare  only  the  supra-pubic  region,  inner  surface 
of  the  thighs  and  the  vulva.  The  number  and  kind  of  solutions 
which  are  used  in  this  preparation  also  vary  greatly,  but  in  gen- 
eral the  shaving  is  followed  by  a  thorough  scrubbing,  by  clean 
hands,  with  green  soap  and  sterile  water,  then  iodin,  lysol  or 
alcohol  and  bichlorid  or  biniodid  solution,  according  to  the  cus- 
tom of  the  doctor.     (Fig.  74.) 

But  the  kind  and  number  of  the  solutions  are  probably  not 
so  important  as  the  nurse's  technique.  Throughout  the  entire 
course  of  the  preparation  she  must  apply  the  principles  of  what 
she  was  taught  about  the  technique  of  preparing  the  skin  for 
an  operation  and  regard  the  perineal  region  in  the  same  light 
as  she  would  the  field  which  was  being  prepared  for  a  major 
operation ;  scrubbing  from  the  centre  toward  the  periphery, 
always,  in  order  not  to  carry  infective  material  from  an  unclean 
to  a  clean  area,  which  in  this  case  is  the  vaginal  outlet. 

The  supra-pubic  region  and  abdomen  are  scrubbed  across, 


250 


OBSTETRICAL  NURSING 


THE  NURSE'S  DUTIES  DURING  LABOR 


251 


back  and  forth,  working  up  from  the  symphysis;  the  strokes 
on  the  thighs  are  up  and  down;  in  the  groin,  down  toward  the 
rectum,  and  away  from  the  vagina,  never  toward  it,  and  fluids 
poured  upon  the  vulval  region  must  never  run  into  the  vagina 
from  over  surrounding  skin.  A  sponge  or  scrub  ball  must  be 
discarded  after  approaching  the  rectum,  or  stroking  away  from 
the  vagina  in  any  direction.  Some  obstetricians  instruct  the 
nurse  to  place  a  firm,  sterile  cotton  pad  or  scrub  ball  between 


Fig.    75. — Patient    draped    for    vaginal    examination;    vulva    covered    Avith 
sterile  towel.   (From  photograph  taken  at  Johns  Hopkins  Hospital.) 

the  labia,  against  the  vaginal  opening  while  scrubbing  and  flush- 
ing the  adjacent  areas,  to  preclude  the  possibility  of  introducing 
fluids.  But  with  a  painstaking  nurse  this  is  scarcely  necessary. 
After  the  surrounding  areas  have  been  prepared,  the  labia 
are  separated  and  the  inner  surfaces  scrubbed,  first  across,  then 
from  above  downward,  and  flushed  by  pouring  the  solution 
directly  between  the  folds.  After  the  patient  has  been  given 
this  preparation,  a  dry  sterile  towel  or  pad  is  placed  over  the 
vulva ;  the  douche  pan  is  removed,  the  back  and  hips  are  dried. 


252  OBSTETRICAL  NURSING 

after  which  the  patient  is  so  draped  with  a  clean  sheet  that  only 
the  perineal  region  is  exposed,  and  a  sterile  towel  is  slipped 
under  the  buttocks.     (Fig.  75.) 

To  summarize  the  preparation  for  vaginal  examination  or 
delivery : 

1.  Trim  nails  and  scrub  bands  witb  soap  and  bot  water. 

2.  Sbave  vulva. 

3.  Scrub  and  soak  bands. 

4.  Scrub  vulva,  inner  surface  of  thigbs  and  lower  abdomen  witb 
green  soap  and  sterile  water,  alcohol,  70%,  and  lastly  bicbloride 
1-1000  or  lysol  1%  or  2%,  using  sterile  sponges  and  taking  care 
not  to  contaminate  vulva  from  surrounding  fields. 

5.  Cover  vulva  witb  sterile  towel  or  pad. 

This  may  be  taken  as  a  description  of  a  fairly  typical  method 
of  preparing  a  patient  for  vaginal  examination  or  for  delivery, 
which  is  widely  employed  and  with  satisfactory  results.  But  it 
is  by  no  means  the  only  satisfactory  procedure,  for  many  other 
and  different  methods  of  preparation  also  are  followed  by  excel- 
lent results,  as  measured  by  the  patient's  temperature  during 
the  puerperium. 

The  details  of  preparation  vary  so  greatly,  even  among  dif- 
ferent doctors  in  the  same  hospital,  that  the  nurse  will  simply 
have  to  bear  in  mind  the  general  principles  of  asepsis  and  anti- 
sepsis, and  adjust  herself  to  the  practices  of  the  individual  doc- 
tor. And  she  must  remember  that  in  spite  of  the  best  planning, 
there  will  be  emergencies  and  precipitate  labors,  when  the  prep- 
aration will  necessarily  be  modified,  and  sometimes  so  curtailed 
that  even  the  bath  and  enema  are  omitted. 

But  in  all  cases  the  nurse  can,  and  must,  bear  in  mind  that 
on  one  point  there  is  virtually  no  difference  of  opinion  among 
obstetricians  of  to-day ;  and  that  is  the  imperative  necessity  of 
having  everything  sterile  that  is  brought  to  the  perineal  region 
or  used  in  any  way  in  connection  with  the  delivery,  or  as  nearly 
sterile  as  is  possible  under  the  circumstances. 

By  many  doctors  this  is  considered  the  most  important 
factor,  as  to  surgical  cleanliness,  in  the  entire  preparation.  In 
their  opinion  the  local  preparation  of  the  patient  may,  with 
safety,  be  restricted  to  clipping  the  pubic  hairs  (instead  of  shav- 


THE  NURSE'S  DUTIES  DURING  LABOR  253 

ing),  and  scrubbing  the  vulva  with  only  soap  and  water.  But 
these  doctors  believe  at  the  same  time  that  the  patient  is  dan- 
gerously susceptible  to  infection  which  may  be  conveyed  to  her 
from  without,  and  accordingly  they  do  not  permit  vaginal 
examinations  to  be  made  during  labor,  and  make  the  most  ex- 
acting demands  concerning  the  maintenance  of  perfect  surgical 
technique,  by  all  who  assist  with  the  delivery. 

In  this  connection,  much  depends  upon  the  actual  steriliza- 
tion of  the  rubber  gloves,  either  by  boiling  or  by  steam  under 
pressure ;  and  the  method  of  putting  on  the  gloves,  in  order  that 
once  having  been  sterilized,  they  may  be  kept  so.  It  is  useless 
to  attempt  to  sterilize  gloves  by  boiling,  if  they  are   thrown 


Fig.  76. — Wrong  and  right  methods  of  boiling  gloves.  Note  that 
gloves  in  basin  at  the  left  are  partly  above  the  surface  of  the  water  and 
therefore  will  not  be  sterilized.  Those  in  basin  at  the  right  are  kept  below 
the  surface  by  the  weight  of  the  towel  and  will  be  sterilized  by  the  boiling 
water. 


loosely  into  a  kettle  of  water.  There  will  practically  always 
be  enough  air  in  the  fingers  to  keep  at  least  a  part  of  the  gloves 
out  of  the  water,  and  consequently  unaffected  by  its  heat.  They 
should  be  put  into  a  covered  wire  basket  that  will  be  entirely 
submerged,  or  they  may  be  wrapped  in  a  towel,  the  weight  of 
vvhich  will  carry  them  below  the  surface  of  the  water  (Fig.  76), 
and  insure  their  being  completely  covered  while  boiling,  which 
should  continue  for  ten  to  fifteen  minutes.  The  doctor  will 
usually  want  boiled  gloves  placed  in  a  large  basin  of  bichlorid 
solution,  1-1,000,  or  lysol  2  per  cent.,  from  which  he  may  remove 
them  after  scrubbing  his  hands.  If  dry  gloves  are  used,  there 
should  be  in  readiness  a  sterile  towel  and  powder  with  which  to 


254 


OBSTETRICAL  NURSING 


dry  and  powder  the  hands  before  putting  on  the  gloves.     (Fig. 
77.) 

Whether  boiled  or  steamed,  the  cuffs  of  the  gloves  should 
first  be  turned  up  toward  the  hand,  to  make  it  possible  to  put 
them  on  without  touching  the  glove  fingers  with  ungloved  hands. 
(Fig.  78.)  For  no  matter  how  long  and  carefully  the  hands  are 
scrubbed  and  soaked,  they  cannot  be  made  absolutely  sterile, 


i      ^  ^wv 

l^^^^il...,^^^^^^^^^      ^mm^M      ^^,  ^ 

Fig.   77. — Powdering  hands  before  putting  on  dry  gloves.      (From  photo- 
graph taken  at  the  Brooklyn  Hospital.) 


and  therefore,  in  relation  to  the  gloves  which  are  sterile,  the  bare 
hands  must  always  be  regarded  as  unclean.  Too  much  thought 
and  attention  cannot  be  given  to  the  sterilization  and  handling 
of  the  gloves,  for  the  patient's  very  li^'e  may  depend  upon  their 
aseptic  condition. 

After  the  doctor  has  seen  the  patient,  the  nurse  will  make 
observations  and  communicate  with  him  in  accordance  with  in- 


THE  NURSE'S  DUTIES  DURING  LABOR 


255 


structions  which  she  must  make  sure  to  obtain  from  him  at  that 
time.  Many  doctors  Avish  to  be  with  a  primipara  continuously 
from  the  time  the  cervix  is  completely  dilated,  and  with  multi- 
paras after  it  is  half  dilated.    But  that,  of  course,  is  a  matter 


Fig.  78. — Successive  steps  in  proper  method  of  putting  on  sterile  gloves 
to  avoid  contaminating  outside  of  gloves  with  bare  fingers.  (From  photo- 
graphs taken  at  the  Long   Island  College  Hospital.) 

which  each  doctor  decides  for  himself.  The  nurse's  responsi- 
bility is  to  learn  his  wishes. 

Watch fulnesa,  then,  is  of  extreme  importance;  watching 
for  symptoms  of  complications  or  change  in  the  patient's  condi- 
tion, and  watching  the  progress  of  labor  in  order  to  keep  the 
doctor  fully  informed  about  his  patient's  condition.  Nurses 
are  very  frequently  taught  to  make  rectal  examinations  for  the 
sake  of  increasing  the  value  of  their  assistance  in  this  respect. 

Although  unexpected  symptoms  do  not,  as  a  rule,  develop 


256  OBSTETRICAL  NURSING 

suddenly  during  the  first  stage,  the  nurse  must  be  none  the  less 
vigilant  for  them.  The  doctor  should  be  notified  if  the  pains 
suddenly  grow  either  more  or  less  frequent,  or  more  or  less 
severe ;  if  there  is  any  bulging  of  the  perineum ;  if  the  membranes 
rupture;  if  there  is  any  bleeding  or  a  prolapsed  cord;  if  there 
is  extreme  restlessness  or  any  evidence  of  unusual  distress;  a 
rising  temperature  or  pulse ;  a  temperature  of  100°  F.  or  a  pulse 
of  more  than  100  or  less  than  60 ;  a  fetal  heart  rate  of  more  than 
150  or  less  than  116,  or  any  marked  change  of  any  kind  in  the 
patient's  condition. 

During  the  latter  part  of  the  first  stage,  and  during  the 
second  stage,  the  patient  has  an  almost  continuous  desire  to 
empty  her  bowels,  because  of  pressure  made  upon  the  rectum 
by  the  descending  head.  This  is  another  point  which  the  nurse 
may  explain  to  her  patient,  in  assuring  her  that  frequent  at- 
tempts to  use  the  bed-pan  will  give  no  relief. 

The  end  of  the  -first  stage  is  reached  when  the  cervix  is  fully 
dilated,  at  which  time  the  pains  occur  about  every  two  minutes, 
are  stronger  and  more  severe,  and  the  patient  begins  to  feel  like 
bearing  down.  The  membranes  frequently  rupture  at  this  point 
and  the  vaginal  discharge  is  blood  tinged.  The  patient  should 
remain  in  bed  and  not  be  left  alone  from  this  time  on. 

To  sum  up  the  nurse's  duties  during  the  first  stage  of  labor, 
when  the  patient  is  almost  entirely  in  the  nurse 's  care : 

1.  She  must  be  a  sympathetic,  encouraging  friend  to  the  patient 

2.  She  must  help  the  patient  to  preserve  her  strength  by  giving 
her  light  nourishment  about  every  four  hours;  by  advising  her 
not  to  bear  down;  not  to  exhaust  herself  by  walking  about  too 
much  but  to  lie  down  when  tired. 

3.  She  must  watch  the  progress  of  labor  and  watch  for  symptoms 
of  complications. 

4.  She  must  employ  strictest  aseptic  and  antiseptic  methods. 

5.  She  must  prepare  for  the  birth  of  the  baby. 

SECOND  STAGE 

The  second  stage  is  shorter,  harder  and  more  perilous  than 
the  first.  The  uterine  contractions  are  stronger ;  more  frequent 
and  more  expulsive,  and  the  baby  steadily  curves  and  rotates 
its  way  down  through  the  birth  canal. 


THE  NURSE'S  DUTIES  DURING  LABOR  257 

With  the  onset  of  the  second  stage  the  nurse  should  complete 
the  preparations  for  the  baby 's  birth,  bearing  in  mind  that  with 
a  primipara  the  baby  probably  will  not  come  for  an  hour  and 
a  half  or  two  hours,  but  may  come  in  half  an  hour  or  less  if  the 
patient  is  a  multipara.  Everything  which  is  to  be  used  should 
be  conveniently  placed,  but  the  packages  are  not  necessarily 
opened  at  this  time. 

In  addition  to  the  sterile  dressings,  basins,  gloves,  instru- 
ments and  various  other  articles  which  have  been  enumerated, 
the  nurse  must  remember  that  there  should  be  for  the  baby  a 
box  or  basket  lined  with  a  blanket  and  containing  one,  or  pre- 
ferably two,  hot-water  bottles  at  125°  F. ;  in  hospitals,  an  adhe- 
sive strip  for  the  baby 's  name  or  a  name  necklace ;  a  binder  of 
flannel  or  sterile  gauze,  according  to  the  custom  of  the  doctor ; 
sterile  olive  oil  or  albolene  for  the  first  oiling  and  one  or  two 
tubs,  in  case  the  baby  needs  to  be  resuscitated. 

There  will  be  needed,  also,  a  covered  basin  for  the  placenta; 
chloroform  and  an  inhaler;  Wassermann  tubes,  for  those  doc- 
tors who  make  this  test  as  a  routine;  hypodermic  syringe  and 
needles,  with  pituitrin,  ergotole  and  drugs  for  stimulation  which 
the  doctor  may  specify.     (Figs.  79,  80.) 

In  the  meantime,  the  force  and  frequency  of  the  pains  should 
be  noted,  and  some  doctors  require  a  record  of  both  the  fetal 
and  maternal  pulse  rate  every  half  hour,  and  notification  if  the 
baby's  is  over  150  or  below  116,  or  the  mother's  over  100  or 
below  60.  Extreme  restlessness,  distress,  vaginal  bleeding,  pro- 
lapsed cord,  a  temperature  of  100°  F.,  or  any  marked  change 
must  be  communicated  to  the  doctor  immediately,  if  it  occurs 
before  he  has  started  for  his  patient. 

The  patient  may  complain  of  intense  pain  in  her  back  and 
cramps  in  her  legs  during  the  second  stage.  Pressure  made 
by  the  nurse's  hand,  or  a  small  pillow  slipped  under  the  small 
of  the  back  will  frequently  relieve  the  backache,  while  cramps 
in  the  legs  may  be  relieved  by  straightening,  and  slightly  elevat- 
ing the  leg,  and  rubbing  it  while  in  that  position.  As  these  pains 
are  usually  due  to  pressure  they  have  no  serious  significance 
and  subside  as  soon  as  the  child  is  born. 

The  nurse  may  find  herself  in  any  one  of  three  situations 


258 


OBSTETRICAL  NURSING 


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during  the  second  stage.  The  doctor  may  arrive  in  ample  time 
to  conduct  the  delivery;  he  may  be  slightly  delayed  and  the 
nurse  endeavor  to  retard  labor,  according  to  instructions;  or 
the  baby  may  be  born,  with  or  without  the  expulsion  of  the 
placenta,  before  his  arrival. 

When  the  doctor  arrives  at  the  onset  of,  or  during  the  second 
stage  of  labor,  the  nurse  acts  solely  under  his  direction,  the 
nature  of  her  offices  depending  somewhat  upon  the  condition  and 
surroundings  of  the  patient,  and  whether  or  not  the  nurse  is 
the  only  person  at  hand  to  give  assistance.  In  any  case,  the 
gloves,  and  instruments  for  repairing  a  tear  should  be  boiled 
and  in  readiness;  the  dressings  and  other  articles  to  be  used 


PiQ.  80. — Instruments  for  normal  delivery  shown  in  boiling  basin  on 
table  in  Fig.  79:  Needle  holder.  Blunt  hook.  Blunt  scissors.  2  small 
Kelly  clamps.  Mouse  tooth  forceps.  4  towel  clips.  2  large  perineal 
needles  and  2  cervical  needles  in  gauze  sponge. 

are  to  be  conveniently  arranged  upon  the  tables  and  opened  at 
the  proper  time. 

After  having  everything  ready  and  at  hand  for  the  delivery, 
the  nurse  may  be  called  upon  to  clean  up  and  act  as  an  assistant, 
or  to  give  the  anesthetic.  If  she  cleans  up,  she  should  wear  a 
sterile  gown  and  gloves,  and  if  it  is  the  doctor's  custom,  a  cap 
and  mask  as  well,  having  prepared  her  hands  somewhat  as  fol- 
lows :  ^ 

1.  Scrub  hands  and  arms  with  hot  water  and  green  soap  for  five 
minutes,  paying  especial  attention  to  the  fingers  and  nails. 

2.  Clean  and  trim  nails  and  scrub  again  for  five  minutes. 

*  Routine  preparation  of  hands  at  Johns  Hopkins  Hospital. 


THE  NURSE'S  DUTIES  DURING  LABOR 


261 


262 


OBSTETRICAL  NURSING 


3.  Soak  and  scrub  hands  and  forearms  in  alcohol,  70%,  for  two 
minutes. 

4.  Soak  in  bichloride  solution,  1-1000,  for  five  minutes, 

5.  Put  on  gloves  out  of  second  bichloride  solution,  avoiding  con- 
tact with  fingers  of  ungloved  hand.     (See  Fig.  78.) 


Pig.  82. — Patient  draped  with  sterile  towels,  leggings,  sheet  and  de- 
livery pad  for  delivery.  (From  photograph  taken  at  Johns  Hopkins 
Hospital.) 

The  patient  is  given  a  final  scrubbing  with  green  soap  and 
sterile  water  and  an  antiseptic  solution,  by  some  one  with  clean 
hands,  and  is  further  protected  by  means  of  sterile  leggings,  a 
sterile  towel  across  the  abdomen  and  one  covering  the  inner  sur- 
face of  each  thigh,  held  in  place  by  sterile  clips  or  safety  pins. 


THE  NURSE'S  DUTIES  DURING  LABOR  263 

The  lower  half  of  the  bed  is  covered  with  a  sterile  sheet  while  a 
sterile  delivery  ])a(l  is  sli])p('d  under  the  patient's  hips.  (Fig. 
82.) 

If  the  delivery  is  made  with  the  patient  lying  on  her  side, 
the  sterile  dressings  are  so  arranged  as  to  cover  all  but  the 
perineal  region  after  she  is  placed  in  the  desired  position. 

This  brings  up  the  question  of  the  nurse's  obligation  to  pro- 
tect her  patient  from  tlio  embarrassment  of  unnecessary  ex- 
posure at  any  time  during  lal)or.  The  field  which  is  prepared 
must  be  uncovered  temporarily,  and  while  the  patient  is  being 
draped  for  examination  or  delivery  a  certain  amount  of  exposure 
is  unavoidable ;  but  there  are  many  little  ways  in  which  the  nurse 
may  show  her  consideration  for  the  patient  in  this  connection 
and  the  patient  always  appreciates  the  protection. 

During  the  second  stage,  the  preservation  of  asepsis,  watch- 
ing the  progress  of  lal)or  and  watching  for  unfavorable  symp- 
toms, are  of  even  greater  importance  than  during  the  first  stage. 
After  the  patient  has  been  prepared  and  draped  with  sterile 
dressings,  neither  they  nor  the  perineal  region  should  be  touched 
with  anything  unsterile. 

If  for  any  reason  it  has  not  been  possible  to  sterilize  sheets 
and  toAvels,  or  more  are  needed  after  the  prepared  supply  has 
been  exhausted,  the  inner  surfaces  of  towels  and  sheets  that  have 
been  ironed  either  by  hand  or  machinerj',  and  folded  with  the 
ironed  surfaces  inside  without  being  touched,  may  be  regarded 
as  practically  sterile. 

As  the  second  stage  advances,  the  patient  may  gi'eatly  aid 
the  progress  of  labor  by  voluntarily  bearing  down  during  pains, 
and  the  nurse  in  turn  may  be  called  upon  to  hel))  by  encourag- 
ing her  and  explaining  just  what  she  should  do.  At  the  begin- 
ning of  a  pain  the  patient  should  take  a  deep  breath,  close  her 
lips,  brace  her  feet  and  strain  with  all  her  strength.  If  she  opens 
her  mouth  and  cries  out,  she  fails  to  use  her  pains  to  the  best 
advantage.  The  etfect  of  this  bearing  down  may  be  increased 
by  providing  the  patient  with  straps,  attached  to  the  foot  of 
the  bed,  upon  which  she  may  pull  during  the  contractions,  as 
she  bears  down.  (Fig.  83.)  Or,  what  is  often  a  great  comfort 
to  her,  she  may  pull  upon  the  nurse's  hands  as  the  latter  braces 


264 


OBSTETKICAL  NURSING 


herself  so  as  to  offer  strong  resistance.  If  the  nurse  can  be  spared 
from  other  duties  to  give  this  kind  of  assistance,  it  is  indeed  a 
comfort  to  the  patient,  who  appears  to  derive  from  it  both  a 
moral  and  physical  sense  of  being  helped  in  her  struggle.  It  is 
also  important  to  assure  the  patient,  between  pains,  that  she  is 
doing  well,  and  that  her  efforts  are  advancing  the  baby,  if  this 
is  true ;  and  if  not,  she  may  under  ordinary  conditions  be  urged 
to  make  greater  effort. 

Before  the  head  can  be  seen  at  the  outlet  or  its  advance  noted 


Pig.    83. — Patient   pulling:    on    straps    while   bearing    down    during    second 
stage  pains.     (From  photograph  taken  at  Johns  Hopkins  Hospital.) 


by  perineal  bulging,  the  stage  of  its  descent  is  often  ascertained 
by  palpating  through  the  perineum,  the  fingers  of  a  gloved  hand 
pressing  upward,  on  one  side  of  the  vulva.  (Fig.  84.  See 
Figs.  85,  86,  87,  and  88  for  appearance,  advance  and  birth  of 
head  during  normal  delivery.) 

Immediately  after  the  birth  of  the  head,  and  before  the  birth 
of  the  body,  the  nurse  is  frequently  asked  to  wipe  tlie  baby's 
mouth  and  eyes  and  sometimes  to  drop  nitrate  of  silver  into  the 
eyes.    In  such  a  case  she  should  wipe  out  the  mouth  very  gently 


TIIK  NURSE'S  DUTIES  DURING  LABOR 


267 


iu^  lustily,  in  oi'der  fully  to  expand  its  lunj^s.  This  provides 
for  oxygenation  of  its  blood,  which  has  taken  place,  until  now, 
through  the  placental  circulation.  In  many  cases  the  baby  cries 
satisfactorily  without  aid,  but  not  infrequently  must  be  stimu- 
lated to  do  so.     In  all  instances  the  first  step  is  to  clear  the  air 


Fig.  8G. — Adviince  of  the  head  indicated  by   strctcliiug  of  the  vulva  and 

perineum. 


268 


OBSTETRICAL  NURSING 


FiQ.   87. — Holding  back  the  head  at  the  height  of   a  pain  to  prevent  a 

perineal  tear. 


THE  NURSE'S  DUTIES  DURING  LABOR  269 


y 


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^ 


'SVa*  88. — Birth  of   the  head   immediately   followed   by   external  rotatioA.. 


270 


OBSTETRICAL  NURSING 


passages  of  the  mucus  lodged  in  tlie  mouth  and  throat,  by  some 
one  of  the  many  approved  methods.  One  is  by  means  of  a  piece 
of  wet  sterile  gauze  wrapped  about  the  little  finger,  and  wiped 
gently  about  in  the  back  part  of  the  baby's  mouth   (Fig.  89), 


Fia.   89. — Wiping  mueus  from  baby's  mouth  Avith  gauze  ■wrapped  about 

little  finger. 


though  many  doctors  object  to  this  procedure  for  foar  of  abrad- 
ing the  very  delicate  mucous  membrane,  no  matter  how  lightly 
it  is  done.  They  prefer  to  hold  the  baby  by  its  feet,  with  the 
head  hanging  down  and  the  neck  sharply  curved  Inickward,  when 
by  gravity  the  mucus  will  drop  out  of  the  mouth ;  or,  holding 
the  baby  by  the  feet,  to  run  the  thumb  and  forefinger  along  the 


THE  NUUSKS  DUTIES  Dl'KINCJ  LAIUJU  271 

neck  on  either  side  of  the  trachea,  toward  the  mouth,  and  force 
out  the  mucus  in  that  way.  If  the  l)ahy  does  not  cry  well  after 
the  mucus  is  removed,  it  may  usually  be  stimulated  to  do  so  if 
held  by  the  feet,  head  downward,  and  the  back  gently  rubbed 
(Fig.  90)  or  the  face  stroked  or  the  buttocks  spanked  two  or 
three  times.  When  holding  the  baby  in  this  position  the  nurse 
should  slip  one  finger  between  the  ankles  and  grasp  them  firmly. 


Fig.   90. — Stroking   baby's   back  to   stiiimlate   resi)irations. 

After  the  baby  has  cried  well  it  may  be  laid  on  the  foot  of 
its  mother's  bed.  At  this  juncture  it  seems  pertinent  to  stress 
two  points  which  must  be  remembered  throughout  the  entire 
routine  of  the  baby's  care,  namely:  the  importance  of  protecting 
it  from  infection  and  from  being  chilled.  As  the  baby  lies  on 
the  mother's  bed,  before  the  cord  is  cut,  it  finds  itself  in  a  room 
which  is  many  degrees  cooler  tlian  the  very  warm  habitat  from 
which  it  has  just  emerged;  it  is  struggling  to  establish  its  func- 
tions, which  are  suddenly  deprived  of  the  mother's  help,  chief 


272 


OBSTETRICAL  NURSING 


of  which  at  the  moment  are  respiration  and  the  circulation.  Body 
warmth  is  one  of  the  most  valuable  aids  in  promoting  an  even 
circulation,  and  accordingly  the  baby  should  be  kept  warm  from 
the  beginning.     For  tliis  purpose  tlicre  should  be  a  small  sterile 


Fig.  91. — Showing  two  clamps  on  cord  after  pulsation  has  ceased. 

blanket,  or  piece  of  flannel,  in  readiness  to  protect  the  little  body 
as  it  lies  on  the  bed,  awaiting  further  developments.  The  hands 
and  feet  of  the  newborn  baby  that  lies  uncovered  for  even  a 
quarter  of  an  hour,  or  more,  are  nearly  always  cold,  and  as  this 
must  be  guarded  against  in  an  older,  more  securely  established 
baby,  it  cannot  be  desirable  for  the  newly  born. 

As  soon  as  the  cord  ceases  to  pulsate,  it  is  usually  clamped 


A  B 

Fig.  92. — Wrong  and  right  method  of  tying  knot  in  cord  ligature. 

A  will  slip.     B  will  not. 

with  two  clamps  about  two  inches  apart  (Fig.  91)  and  cut  be- 
tween the  clamps.  The  scissors  should  have  blunt  points,  in 
order  not  to  scratch  or  cut  the  baby,  who  may  be  wriggling 
vigorously  by  this  time.    The  cord  is  tied  tightly  with  a  sterile 


THE  NURSE'S  DUTIES  DURING  LABOR  273 

cord  ligature,  in  a  square  knot  that  will  not  slip  (Pig.  92),  about 
an  inch  from  the  abdominal  wall.  It  is  considered  a  safe  pre- 
caution, after  removing  the  damp,  to  bend  the  cord  back  upon 
itself  and  tie  it  a  second  time  with  the  same  ligature,  as  the 
danger  of  hemorrhage  from  a  loosely  tied  cord  is  serious  when 
the  baby  is  kept  sufficiently  warm.  The  placental  end  of  the 
cord  is  also  tied,  or  it  remains  clamped  until  the  placenta  is 
expelled,  because  of  the  possibility  of  there  being  another  child 
in  the  uterus  and  the  danger  of  its  bleeding  to  death  through 
the  open  cord. 

Some  doctors  do  not  tie  the  cord,  but  crush  the  vessels  with 
a  clamp  which  is  left  on  the  cord  for  about  half  an  hour  and 
then  permanently  removed,  but  this  should  not  be  done  by  a 
nurse  upon  her  own  responsibility. 

Very  often  the  person  who  performs  the  delivery  removes 
the  blood,  mucus  and  vernix  from  the  baby's  body,  as  soon  as 
the  cord  is  tied,  by  sponging  it  thoroughly  with  albolene  or 
olive  oil;  wraps  the  cord  stump  with  a  sterile,  dry  or  alcohol 
sponge  and  applies  the  abdominal  binder  while  an  assistant  holds 
the  baby  by  the  feet,  head  down.  It  is  also  very  common  simply 
to  oil  the  baby  with  unsterile  lard,  oil  or  vaseline,  cover  the  cord 
with  sterile  gauze  and  leave  the  bath,  cord-dressing  and  binder 
to  be  attended  to  later. 

If  the  delivery  takes  j^lace  in  a  hospital  the  baby  must  be 
marked  before  it  is  taken  from  the  delivery  room,  with  adhe- 
sive plaster,  upon  which  its  mother's  name  is  plainly  printed, 
or  with  the  name  necklace,  now  so  frequently  used. 

The  baby  is  once  more  wrapped  in  a  warm  blanket  and  placed, 
with  a  hot -water  bottle,  at  125°  F.,  in  the  basket  or  box,  which 
was  prepared  for  it.  Although  the  baby  should  be  well  covered, 
care  must  be  taken  to  leave  the  face  fully  exposed  as  a  young 
baby  is  easily  suffocated.  It  was  formerly  customary  to  lay  the 
new  baby  on  its  right  side,  but  with  the  present  fuller  knowl- 
edge of  the  fetal  circulation  and  the  changes  which  take  place 
after  birth,  this  practice  has  been  largely  done  away  with. 

Resuscitation  of  the  Newborn  Baby.  If  the  baby  breathes 
feebly,  or  even  if  it  does  not  cry  vigorously,  the  effort  to  stimu- 
late the  respirations  may  have  to  be  continued  for  an  hour  or 


274 


OBSTETRICAL  NURSING 


more  after  the  cord  is  tied.  In  addition  to  the  simple  methods, 
previously  described,  which  are  very  commonly  employed  at 
the  time  of  labor,  such  as  stroking  the  baby's  back  or  holding 
him  by  the  feet  and  spanking  him  (Fig.  93),  the  following 
measures  are  sometimes  resorted  to  if  tlie  baby's  condition  de- 
mands it : 

One  method  is  to  hold  the  baby  with  its  chest  resting  on  the 


T'iG.  93. — Rtiimilatiiiff  respirations  l)y  holdiii}?  the  baby  head  downward 
and  sharply  spanking  liini.  Note  the  method  of  <irasping  the  baby's  ankles 
with  one  finuer  between  them  to  prevent  his  slippinf^-  from  the  nurse's 
liand. 

palm  of  one  hand,  with  head,  legs  and  arms  hanging  forward, 
thus  compressing  the  chest  wall  and  favoring  expiration  (Fig. 
94),  and  then  turning  it  over  on  its  back,  in  the  other  hand, 
in  w'hich  position  the  head,  legs  and  arms  hang  backward,  thus 
pxpanding  the   chest  and  favorhig   an    inspiratory  movement. 


THE  NURSE'S  DUTIES  DURING  LAliGR 


275 


(See  Fig.  95.)  Alternate  repetitions  of  these  positions,  about 
twelve  times  a  minute,  will  often  stimulate  the  child  to  breathe 
satisfactorily. 

Another  method  is  alternately  to  plung^e  the  baby  into  tubs 
of  hot  and  cold  water.    But  as  there  is  doubt  about  the  wisdom 


Fig.  94.     (See  also   Fifj.  Of..) 
Figs.   94  and   95   show  method   of   stimulating  respirations  by  resting 
the  baby  alternately  on  his  chest  and  back  on  the  nurse's  hands.      (From 
photographs  taken  at  Bellevue  Hospital.) 


276 


OBSTETRICAL  NURSING 


of  chilling  the  entire  surface  of  the  baby's  body,  the  cold  plange 
is  forbidden  by  many  doctors,  who,  instead,  dash  a  little  cold 
water  upon  the  face  and  chest,  while  the  body  is  immersed  in 
water  at  about  110°  F. 


Fig.  95. — Eesuseitating  the  baby.     (See  also  Fig.  94.) 

A  widely  used  and  efficacious  method  is  to  hold  the  baby  con- 
tinuously in  a  tub  of  water  at  about  110°  F.,  and  alternately 
extend  and  fold  its  body,  thus  keeping  it  warm  while  stimulating 
inspiration  and  expiration.     (Figs.  96,  97.) 


THE  NURSE'S  DUTIES  DURING  LABOR  277 

Direct  insufflation  may  be  employed  while  the  baby  is  in  the 
warm  water,  by  protecting  its  face  with  clean  dry  gauze  and 
bloAving  directly  into  its  mouth  at  intervals  corresponding  to 
those  of  normal  inspiration.     (Fig.  98.) 


Fig.  96.     (See  also  Fig.  97.) 
Figs.  96  and  97  show  method  of  resuscitating  the  baby  by  alternately 
extending  and  folding   his  body  under   warm  water.      (From  photographs 
taken  at  Johns  Hopkins  Hospital.) 

Another  procedure  is  to  hold  the  baby  by  the  shoulders,  with 
its  body  hanging  down,  thus  expanding  the  chest,  and  then  to 
toss  it  quickly  upwards,  folding  the  legs  upon  the  chest  to  com- 
press it.  This  method  is  objected  to  by  many  obstetricians  on 
the  ground  that  it  both  exhausts  and  chills  the  baby- 


278  OBSTETRICAL  NURSING 

The  outstanding'  requirements  in  resuscitating  a  baby  are  to 
stimulate  its  respiratory  movements,  by  alternately  expanding 
and  contracting  the  chest ;  to  promote  its  circulation  by  keeping 


Fig.  97. — Resuscitating  the  baby.     (See  also  Fig.  96.) 

it  warm,  and  to  avoid  exhausting  the  very  frail  little  body. 
Gentle  handling,  therefore,  is  important. 

THIRD  STAGE 

After  the  birth  of  the  baby,  some  doctors  request  the  nurse 
to  rest  one  hand  on  the  mother's  abdomen  in  order  to  feel  the 


THE  NURSE'S  DUTIES  DURING  LABOR 


279 


fundus  as  it  rises  while  expelling  the  placenta,  and  to  keep  him 
informed  concerning  its  consistency.  Others  regard  this  as  a 
dangerous  practice  and  forbid  it. 

As  a  rule,  there  is  little  bleeding  until  the  placenta  has  sepa- 
rated. If  bleeding  does  occur,  it  is  the  practice  of  some  doctors 
to  have  the  uterus  gently  massaged  through  the  abdominal  wall, 
to  stimulate  contractions,  while  others  consider  tbis  inadvisable. 

After  the  placenta  separates  and  descends  into  the  lower 


Fig.  98. — Stimulating  respiration  by  means  of  direct  insufiflation,  the 
baby's  face  being  covered  with  clean  gauze.  (From  photograph  taken 
at  Johns  Hopkins  Hospital.) 

uterine  segment,  it  produces  a  bulging  just  above  the  symphysis, 
while  the  fundus  may  be  felt  as  a  firm,  hard  ma.ss  above  the 
umbilicus.  Since  the  placenta  is  entirely  separated  from  the 
uterus  at  this  time,  its  complete  expulsion  is  usually  aided,  when 
it  does  not  occur  spontaneously,  by  gentle  pressure  upon  the 
fundus.  Tbe  accoucheur  holds  his  hand  just  below  the  vaginal 
outlet,  to  receive  the  placenta  (Fig.  99),  which  he  turns  over 
and  over  in  his  hands,  thus  twisting  the  membranes,  and  grad- 
ually draws  it  away  from  the  mother,  the  membranes  trailing: 


280 


OBSTETRICAL  NURSING 


after  in  the  form  of  a  tapering  cord.  (Fig.  100.)  It  is  impor- 
tant that  the  placenta  and  membranes  be  carefully  examined 
to  make  sure  that  they  are  intact,  for  if  fragments  of  either 
are  retained  within  the  uterus  they  will  prevent  its  firm  con- 
traction and  thus  may  be  a  cause  of  post-partum  hemorrhage. 
For  this  reason,  only  very  gentle  pressure  and  traction  are  used 
in  expressing  the  placenta  and  withdrawing  the  membranes,  for 
the  use  of  force  might  leave  small  particles  adhering  to  the 


Fig.  99. — Delivery  of  the  placenta. 


uterine  lining,  which  would  otherwise  separate  with  the  rest, 
in  due  time,  as  a  result  of  the  uterine  contractions. 

Having  been  inspected,  the  placenta  should  be  placed  in  a 
covered  receptacle  to  be  disposed  of  as  the  doctor  directs,  as 
many  physicians  make  a  routine  laboratory  examination  of  the 
placenta  and  wish  to  have  it  kept  for  this  purpose. 

With  the  birth  of  the  placenta  comes  a  gush  of  blood,  as  the 
uterine  vessels,  some  of  which  are  as  large  as  a  lead  pencil  at 
this  time,  are  left  wide  and  gaping.  The  bleeding  usually  sub- 
sides very  shortly,  however,  as  the  blood  vessels  are  closed  by 
involuntary  contraction  of  the  network  of  uterine  muscle  fibres 
in  which  they  are  enmeshed,  and  which  are  sometimes  referred 


THE  NURSE'S  DUTIES  DURING  LABOR  281 

to  as  "living  ligatures."  If  the  bleeding  continues,  these  eon- 
tractions  should  be  stimulated  by  massage.  This  is  done  by 
grasping  the  uterus  through  the  abdominal  wall  firmlj'  with 
one  hand  and  kneading  vigorously.  Rubbing  the  top  of  the 
fundus  with  the  fingers  usually  is  not  enough.  The  fundus 
should  be  grasped  by  the  entire  hand ;  the  thumb  curved  across 
the  anterior  surface  and  the  fingers,  directed  deep  into  the  abdo- 
men, behind  it.     (Fig.  101.) 

Pituitrin  or  ergot,  or  both,  are  frequently  given  to  further 
stimulate  contractions  of  the  uterine  muscles.    Since  the  action 


Fig.  100. — Tmsting  the  membranes  while  withdrawing  them  from 
uterus. 

of  pituitrin  is  quick,  but  evanescent,  and  the  effect  of  ergot  is 
slower  and  more  lasting,  both  a  quick  and  lasting  effect  is  ob- 
tained by   giving   them   together. 

The  expulsion  of  the  placenta  ends  the  third  stage  and  com- 
pletes the  process  of  labor. 

Immediate  After-care  of  the  Patient.  Tlie  patient  should 
be  bathed  and  dried  about  the  thighs  and  buttocks,  the  vulva 
being  bathed  with  alcohol  or  an  antiseptic  solution,  and  a  sterile 
perineal  pad  applied.  The  douche-pan,  wet  towels,  delivery  pad 
and  draw  sheet  are  replaced  by  a  dry  draw-sheet  and  a  towel  or 
pad  slipped  under  the  patient's  hips,  while  a  fresh  nightgown 


282 


OBSTETRICAL  NURSING 


THE  NURSE'S  DUTIES  DURING  LABOR  283 

is  put  on  if  the  one  worn  during  labor  is  wet  or  soiled.  The 
perineal  pad  is  very  commonly  held  in  place  by  a  T.  binder,  with 
which  all  nurses  are  familiar,  but  some  doctors  prefer  an  abdomi- 
nal binder  to  which  a  perineal  strap  is  attached.  This  abdominal 
support  may  be  a  straight  swathe  or  a  Scultetus  bandage,  vary- 
ing with  tile  wislu's  of  the  doctor,  and  it  may  or  may  not  be  used 
in  conjunction  with  a  pad,  so  applied  as  to  make  pressure  over 
the  fundus.  Other  doctors  forbid  the  application  of  any  kind 
of  a  perineal  dressing  from  the  time  of  delivery,  but  instead, 
have  a  large,  sterile  pad  slipped  under  the  patient  to  receive  the 
'discharge. 

The  patient  is  usually  tired  and  cold  at  the  conclusion  of 
labor,  and  may  even  have  a  nervous  chill.  Although  this  chill 
is  not  serious,  the  patient  is  none  the  less  uncomfortable,  and 
she  should  be  warmly  covered,  be  given  something  hot  to  drink, 
and  a  hot-water  bag  placed  at  her  feet. 

All  possible  effort  must  now  be  made  to  secure  for  her  rest, 
quiet,  and  an  opportunity  to  sleep.  Every  one  but  the  doctor 
and  the  nurse  had  better  be  excluded  from  the  room,  which 
should  be  absolutely  quiet,  somewhat  darkened  and  well  venti- 
lated. In  addition  to  this,  the  majority  of  doctors  now  require 
that  either  they  or  the  nurse  shall  stay  with  the  patient  and  keep 
one  hand  resting  on  the  fundus  for  at  least  an  hour  after  de- 
livery as  a  safeguard  against  post-partum  hemorrhage.  As  long 
as  the  fundus  is  felt  through  the  abdominal  wall  as  a  firm,  hard 
mass,  its  irregularly  arranged  muscle  fibres  are  contracted  upon 
the  blood  vessels,  and  will  prevent  an  escape  of  blood.  But  if 
the  fundus  feels  soft  and  boggy,  its  muscles  are  relaxed,  the 
constrictions  are  somewhat  released  from  the  open  vessels,  and 
serious  bleeding  may  occur  unless  they  are  stimulated  to  con- 
tract again. 

If  the  Doctor  Is  Delayed.  It  sometimes  liappens  that  labor 
progresses  with  unexpected  rapidity,  or  that  the  doctor  is  de- 
layed in  his  arrival  and  the  nurse  is  accordingly  confronted  with 
the  emergency  of  being  alone  with  the  patient  during  part  or 
all  of  the  delivery. 

When  the  baby  is  making  such  rapid  descent  that  the  nurse 
fears  it  may  be  born  before  the  doctor's  arrival,  she  may  some- 


284  OBSTETRICAL  NURSING 

what  retard  labor  by  covering  her  hand  with  a  folded,  sterile 
towel,  if  she  has  not  had  time  enough  to  put  on  gloves,  and  hold 
back  the  head  by  pressing  against  the  perineum  during  pains, 
at  the  same  time  instructing  the  patient  to  open  her  mouth, 
breathe  deeply  and  try  not  to  bear  down.  It  is  sometimes  easier 
for  the  patient  not  to  bear  down  if  she  lies  on  her  side. 

If  by  mischance,  or  in  spite  of  her  efforts,  the  baby  so  far 
descends  that  the  brow  appears  before  the  doctor's  arrival,  the 
nurse  cannot  safely  hold  it  back  longer  because  of  the  danger 
of  the  baby  becoming  asphyxiated.  She  should,  up  to  this  point, 
hold  the  head  back  during  pains  in  order  that  the  perineum 
may  be  stretched  slowly,  with  the  hope  of  preventing  a  tear. 
(See  Fig.  87.)  It  is  the  sudden  distension  of  the  perineum  and 
expulsion  of  the  baby's  head  at  the  height  of  a  pain  that  fre- 
quently causes  lacerations.  If  fecal  matter  is  expressed  during 
pains,  the  field  should  be  wiped,  downward,  with  sterile  sponges 
and  bathed  with  the  antiseptic  solution  at  hand. 

After  the  brow  is  born,  the  nurse  may  gradually  release  the 
pressure  and  allow  the  head  to  emerge,  and  remembering  the 
position  of  the  child  and  the  mechanism  of  its  birth,  assist 
Nature  in  its  complete  delivery.  After  the  head  is  born,  it  drops 
down  toward  the  mother's  rectum,  after  which  external  rotation, 
or  restitution,  takes  place.  (See  Fig.  88.)  A  finger  should  be 
slipped  around  the  neck  in  search  of  coils  of  cord,  which,  if  felt, 
should  be  slipped  over  the  baby's  head.  Otherwise,  pressure 
upon  the  cord  in  that  unnatural  position  might  so  interfere  with 
the  circulation  as  to  asphyxiate  the  baby. 

The  shoulders  may  be  born  spontaneously  or  the  nurse  may 
grasp  the  head  with  both  hands,  curving  the  fingers  of  one  hand 
under  the  baby's  chin,  and  of  the  other,  under  the  occiput,  and 
make  gentle,  downward  traction  (See  Fig.  69)  in  order  to  slip 
the  anterior  shoulder  from  under  the  symphysis;  and  then  pull 
gently  upward,  to  deliver  the  lower  or  posterior  shoulder  (see 
Fig.  70),  after  which  the  rest  of  the  body  follows  easily. 

This  description  of  how  a  nurse  may  conduct  a  normal  de- 
livery by  fairly  typical  and  generally  approved  methods  is  only 
intended  to  guide  her  in  an  emergency,  when  there  has  been  no 
understanding  between  her  and  the  doctor  about  what  she  should 


THE  NURSE'S  DUTIES  DURING  LABOR  285 

do  in  event  of  his  absence ;  or  when  he  has  authorized  her  to  use 
her  best  judgment  in  safeguarding  the  lives  of  mother  and  baby. 

It  is  obviously  of  extreme  importance  for  the  nurse  to  ascer- 
tain definitely  the  doctor's  wishes  in  this  connection,  as  he  some- 
times will  be  unwilling  to  have  the  nurse  give  any  attention  to 
either  mother  or  baby,  even  to  tie  the  cord,  before  his  arrival. 

Prolapsed  Cord.  If  the  umbilical  cord  should  prolapse  at 
any  time  during  labor,  in  the  absence  of  the  doctor,  or  lacking 


Fig.   102. — Drawing   showing  how  prolapsed  cord  may  be  pressed  be- 
tween baby  's  head  and  pelvic  brim^  thus  cutting  off  placental  circulation. 

instructions,  the  nurse  should  elevate  the  patient 's  hips,  in  order 
that  gravity  may  lessen  the  pressure  on  the  cord  as  it  lies  be- 
tween the  presenting  part  and  the  pelvic  brim.  Otherwise,  the 
interference  with  the  placental  circulation  may  result  in  asphyx- 
iation of  the  baby.     (Fig.  102.) 

The  elevated  Sims  position  is  often  effective.     Or,  a  straight 
chair  may  be  upturned  and  pushed  under  the  mattress,  from 


286  OBSTETRICAL  NURSING 

the  foot  toward  the  head,  in  such  a  way  that  the  patient  will  be 
lying  on  an  incline  which  slopes  upward  from  the  head  of  the 
bed  toward  the  foot.  Or  the  chair  may  be  placed  in  the  same  posi- 
tion on  top  of  the  mattress,  with  the  top  of  the  chair-back  under 
the  patient's  shoulders.  The  chair  should  be  padded  with  pil- 
lows in  order  to  minimize  the  patient's  discomfort  as  she  lies 
in  this  trying  position, 

Post-partum  Hemorrhag'e.  Should  a  post-partum  hemor- 
rhage occur,  in  the  absence  of  the  doctor,  the  nurse  should  mas- 
sage the  fundus,  unless  she  has  been  instructed  not  to,  and  have 
some  one  elevate  the  foot  of  the  bed  on  blocks  or  the  seat  of  a 
firm,  straight  chair.  The  use  of  ice  bags  or  cold  compresses  on 
the  abdomen  is  sometimes  helpful  and  some  physicians  advise 
placing  the  baby  at  the  mother's  breast  immediately,  since  the 
suckling  stimulates  the  uterine  muscles  to  contract. 

In  anticipation  of  a  post-partum  hemorrhage,  the  nurse  must 
have  a  clear  understanding  of  the  doctor's  wishes,  particularly 
in  regard  to  the  administration  of  pituitrin  and  ergot  which 
are  so  widely  and  efficaciously  used  to  check  post-partum  bleed- 
ing. 

ANESTHETICS 

Those  of  us  who  are  accustomed  to  seeing  anesthetics  used 
to  relieve  patients  of  the  worst  of  their  pain,  during  labor,  find 
it  hard  to  realize  that  until  comparatively  recent  years  women 
went  through  this  suffering  without  mitigation. 

The  use  of  anesthesia  was  introduced  into  obstetrical  prac- 
tice, in  1847,  by  Sir  James  Y.  Simpson  of  Scotland,  who  first 
used  ether  but  later  adopted  chloroform  when  he  learned  that  it 
also  had  anesthetic  properties.  Its  use  in  America  was  subse- 
quently introduced  by  Dr.  Channing  of  Boston. 

In  the  early  days,  the  idea  of  using  anesthesia  during  labor 
was  greeted  Avith  a  storm  of  protest,  both  from  the  clergy  and 
the  laity,  because  of  their  belief  that  the  relief  of  women  in  child- 
birth was  contrary  to  the  teachings  of  the  Bible,  as  set  forth  in 
God's  curse  on  Eve,  when  He  said,  "In  sorrow  thou  shalt  bring 
forth  children." 

There  is  to-day  practical  unanimity  of  opinion  concerning 
the  advantages  which  are  derived  from  the  use  of  anesthesia 


THE  NURSE'S  DUTIES  DURING  LABOR 


287 


when  any  operative  procedures  are  employed ;  but  there  is  still 
some  objection  to  its  use  in  spontaneous  deliveries.  Tiiis  is  partly 
on  medical  grounds  because  of  the  possible  ill  etl'ects  of 
anesthetics  and  is  partly  a  persistence  of  the  early  religious  pro- 
test. However,  in  the  vast  majority  oi"  cases,  some  kind  of  an 
anesthetic,  or  analgesic,  is  administered  to  the  woman  in  labor 
because  the  advantages  of  its  use  are  generally  conceded. 

The  agents  used  are  chloroform,  ether  and  nitrous  oxid  gas, 


Fig.    103. — Method    of    giving    chloroform    for    obstetrical    aiifpsUiesia. 

while  what  is  popularly  called  "tAvilight  sleep"  is  produced, 
completely  or  in  a  modified  degree,  by  the  hypodermic  adminis- 
tration of  scopolamin  and  morphine. 

Chloroform.  Of  these  various  drugs  chloroform  is  appar- 
ently the  anesthetic  most  widely  used  in  normal  obstetrics.  Its 
advantages  are  that  it  is  easy  to  give ;  (juick  in  its  action  and  is 
followed  by  little  or  no  nausea  or  other  ill  effects.  For  some  rea- 
son, as  yet  not  explained,  the  woman  in  labor  enjoys  a  certain 
amount  of  immunitj'  against  chloroform  poisoning,  but  this  toler- 


288  OBSTETRICAL  NURSING 

ance  exists  only  during  labor  as  the  puerperal  woman  is  subject 
to  the  same  dangers  as  any  other  individual. 

Chloroform  is  not  usually  administered  until  the  patient  is 
well  along  in  the  second  stage,  or  until  the  head  may  be  felt 
through  the  perineum,  or  is  in  sight.  The  patient's  face  should 
be  oiled  and  protected  with  a  towel  or  gauze  folded  across  her 
brow,  mouth  and  chin  to  prevent  burns  that  might  follow  the 
inadvertent  dropping  of  chloroform  on  her  face.  With  the  be- 
ginning of  a  pain,  a  few  drops  are  poured  on  the  inhaler  which 
is  held  about  an  inch  from  the  face  to  give  a  free  admixture 
of  air,  and  the  patient  is  told  to  breathe  in  deeply.  (Fig.  103.) 
The  inhaler  is  removed  as  soon  as  the  pain  subsides,  but  reapplied 
as  soon  as  another  pain  begins.  The  patient  retains  conscious- 
ness and  is  able  to  talk  under  this  degree  of  anesthesia,  but  her 
suffering  is  greatly  relieved.  It  has  the  advantage,  also,  of 
lessening  the  danger  of  perineal  tears,  as  the  accoucheur  has 
better  control  of  the  delivery  when  the  patient  lies  quietly  than 
when  she  tosses  violently  about  the  bed,  and  a  tear  resulting 
from  the  sudden  delivery  of  the  head  at  the  height  of  a  pain 
may  in  this  way  be  averted. 

This  light,  intermittent  anesthesia,  now  so  widely  used,  is 
called  obstetrical  anesthesia  or  anesthesia  a  la  reine,  after  Queen 
Victoria,  upon  whom  it  was  first  employed  at  the  birth  of  her 
seventh  child,  in  1853. 

When  the  perineum  is  distended  to  its  maximum,  obstetrical 
anesthesia  is  not  always  sufficient,  and  complete  anesthesia  may 
be  employed ;  but  even  this  requires  very  little  chloroform. 
Under  ordinary  conditions,  the  anesthesia  is  discontinued  as 
soon  as  the  child  is  born,  for  unless  there  is  an  extensive  tear, 
the  patient  is  sufficiently  anesthetized  to  permit  of  a  perineal 
repair  and  the  delivery  of  the  placenta. 

Chloroform  is  not  often  given  early  in  labor  because  of  the 
general  belief  that  its  free  or  prolonged  use  lessens  the  force 
and  frequency  of  uterine  contractions,  thus  prolonging  labor, 
and  also  may  unfavorably  affect  the  child.  But  small  doses  seem 
to  stimulate  rather  than  retard  contractions,  and  by  having  her 
pain  relieved,  the  patient  is  prompted  to  make  greater  effort  to 
use  her  abdominal  muscles,  an  end  greatly  to  be  desired. 


THE  NURSE'S  DUTIES  DURING  LABOR 


289 


If  complete  anesthesia  is  needed  for  more  than  a  few  mo- 
ments, after  the  child  is  born,  ether  usually  replaces  the  chloro- 
form, being  considered  more  satisfactory  for  prolonged 
anesthesia,  but  many  obstetricians  prefer  not  to  give  it  until 
after  delivery  because  of  its  possible  effect  upon  the  child. 


Fig.  104. — Giving  ether  for  obstetrical  anaesthesia.  Ether  is  ])oured 
into  cone  whicli  is  covered  with  nurse's  hand  to  j)revent  evaporation. 
When  the  beginning  of  a  contraction  is  folt  l)y  liand  on  abdomen,  the 
cone  is  placed  about  an  inch  from  the  patient's  face.  (From  photograph 
taken  at  the  Maternity  Hospital,  Cleveland.) 

As  chloroform  poisoning  is  likely  to  produce  degenerative 
changes  in  the  liver,  and  eclampsia  also  causes  a  liver  necrosis, 
chloroform  is  not  used  for  an  eclamptic  patient. 

Ether,  also,  is  used  widely  in  normal  obstetrics  and  is  al- 
most always  preferred  for  continuous  anesthesia,  because  of  its 


290 


OBSTETRICAL  NURSING 


being  safer  than  chloroform.  Unlike  chloroform,  ether  is  some- 
times given  in  the  first  stage  after  the  pains  have  become  severe 
and  frequent.  About  a  dram  of  ether  is  poured  into  the  cone 
which  is  held  just  off  the  patient's  face  (Fig.  104)  until  the 
beginning  of  a  contraction,  at  which  time  it  is  lowered  and  held 


Fig.  105. — As  pain  increases  and  patient  becomes  accustomed  to  ether, 
the  cone  is  lowered  and  held  close  to  her  face  until  pain  subsides.  Suf- 
ficient ether  to  control  the  next  pain  is  then  poured  into  cone.  (From 
photograph  taken  at  the  Maternity  Hospital,  Cleveland.) 


close  to  her  face  (Fig.  105.)  As  the  action  of  ether  is  slower 
than  chloroform,  it  should  be  poured  into  the  cone  in  advance 
of  a  pain,  which  the  nurse  anticipates  by  feeling  the  uterus 
begin  to  grow  hard  under  the  hand  which  she  keeps  upon  the 
patient's  abdomen.     If  the  ether  is  not  poured  into  the  cone 


THE  NURSE'S  DUTIES  I)URL\G  LABOR  291 

until  a  pain  begins,  its  anesthetic  effect  may  be  lost  because  of 
the  delay  in  its  administration. 

At  the  Cleveland  Maternity  Hospital,  where  etiier  is  used 
during  normal  labor,  the  nurses  are  taught  to  give  it  as  has 
just  been  described,  with  further  instructions  from  Miss  Mac- 
Donald,  as  follows:  "A  patient  will  vaporize  about  one  dram 
of  ether  per  pain  during  the  early  first  stage,  gradually  vaporiz- 
ing a  greater  amount  until  she  will  vapori/e  two  or  three  drams 
per  pain  near  the  end  of  the  second  stage.  Should  tlie  patient 
reach  the  excitement  stage  of  etlier  before  she  is  in  the  second 
stage  of  labor,  discontinue  the  ether  for  from  five  to  fifteen 
minutes,  then  give  a  lessened  amount. 

"Should  it  be  necessary  to  control  the  descent  of  the  pre- 
senting part,  light  anesthesia  may  be  given.  This  may  be  man- 
aged by  putting  al)out  two  drams  of  etlier  in  the  cone  at  intervals 
frequent  enough  to  sufficiently  retard  the  descent  of  the  present- 
ing part.  This  procedure  almost  obliterates  contractions.  Lift 
the  cone  from  the  face  for  a  few  moments  at  frequent  intervals 
to  admit  air.  Keep  the  ether  vapor  of  such  concentration  as 
avoids  choking,  coughing  or  vomiting.  This  may  be  done  by 
administering  a  small  amomit  frequently,  rather  than  a  large 
amount  at  longer  intervals.  When  the  desired  stage  is  reached, 
try  to  keep  the  patient  at  this  degree  of  anesthesia  by  giving  a 
few  drams  of  anesthetic  at  regular  intervals." 

Nitrous  Oxid  Gas  Analgesia.  The  effect  of  this  drug  is 
termed  analgesia  rather  than  anesthesia,  because  the  patient  does 
not  lose  consciousness  but  is  unconscious  of  pain.  From  a  med- 
ical standpoint  it  is  considered  practically  ideal  for  use  in 
obstetrics.  If  given  skillfully  it  seems  to  have  no  bad  effects 
upon  the  child ;  it  tends  to  stimulate,  rather  than  diminish  uterine 
contractions;  it  may  be  started,  with  safety,  as  soon  as  the  patient 
begins  to  suffer  severely,  and  continued  for  several  hours  if 
necessary. 

Its  disadvantages  are  that  it  is  very  expensive;  it  can  be 
given  safely  only  by  a  skillful,  trained  person;  the  apparatus 
necessary  for  its  administration  is  expensive,  heavy  and  difficult 
to  transport.  But  when  these  difficulties  can  be  overcome,  its 
use  is  attended  with  very  satisfactory  results. 


292  OBSTETRICAL  NURSING 

"Twilight  Sleep,"  so  called,  or  Ddmmerschlaf,  as  it  is 
termed  in  Germany,  has  been  and  still  is  discussed  so  widely, 
that  the  nurse  should  know  something  of  it,  whether  or  not  she 
aids  in  its  administration.  It  may  be  described  as  a  state  of 
amnesia,  or  forgetfulness,  produced  by  the  hypodermic  injection 
of  morphin  and  seopolamin.  The  patient,  therefore,  is  conscious 
of  pain  at  the  time  but  speedily  forgets  it. 

This  treatment  was  first  used  widely  in  Freiburg.  Follow- 
ing an  enthusiastic  report  from  there  upon  a  large  number  of 
cases  in  which  it  had  been  used,  there  was  such  a  clamor  for 
it  by  American  women,  that  its  temporary  use  was  practically 
forced  upon  obstetricians  in  this  country.  It  Avas  given  what 
appears  to  have  been  a  fair  trial,  but  its  continued  use  in  this 
country  has  not  been  widespread.  Those  obstetricians  who  ob- 
ject to  its  use  describe  its  disadvantages  as  follows:  It  cannot 
be  used  outside  of  a  well-conducted  hospital;  it  requires  the 
constant  attendance  of  a  well-trained  obstetrician  or  obstetrical 
nurse  throughout  the  entire  course  of  labor;  it  is  suitable  for 
use  in  certain  selected  normal  cases  only ;  it  prolongs  the  second 
stage  and  increases  the  percentage  of  cases  in  which  operative 
interference  is  necessary;  it  has  an  asphyxiating  effect  upon 
the  child  and  increases  the  percentage  of  fetal  deaths. 

On  the  other  hand,  the  use  of  seopolamin  and  morphin  is  a 
routine  in  certain  excellent  maternity  hospitals,  and  by  many 
obstetricians  of  the  first  rank,  who  maintain  that  with  a  nurse 
in  attendance  and  the  observance  of  ordinary  precautionary 
measures,  the  advantages  far  outweigh  the  disadvantages  of  a 
modified  "twilight  sleep."  An  anesthetic  is  usually  adminis- 
tered during  the  second  stage,  after  the  use  of  the  scopolamin- 
morphin  treatment. 

Complete  Anesthesia.  If  an  emergency  should  arise  and 
the  nurse  be  required  to  change  from  the  light  anesthesia  a  la 
reine,  and  to  give  complete  anesthesia,  her  responsibilities  in- 
crease, for  she  must  watch  carefully  the  patient's  pulse,  respira- 
tions, color  and  pupils.  The  flat  pillow  which  is  ordinarily  left 
under  the  patient's  head  during  normal  labor,  should  be  removed 
and  the  inhaler  should  be  held  closely  over  her  face  with  the 


THE  NURSE'S  DUTIES  DURING  LABOR 


293 


nurse 's  fingers  so  placed  as  to  hold  it  in  position  and  also  to  hold 
the  patient's  jaw  forward  and  up.     (Ficr.  106.) 

The  ether  sliould  he  dropped  in  clean  drops,  not  poured,  upon 
the  inhaler.  The  dripping  should  he  steady,  hut  slow  at  first, 
gradually  increased  as  the  patient  becomes  accustomed  to  the 
fumes. 

With  the  average,  normal  patient  who  is  taking  ether  well  the 


Fig.  lOG. — Method  of  lioMing  inhaler  aiul  .supimithig-  patient's  jaw 
in  giving  etlier  for  complete  anesthesia.  (From  photograph  taken  at  Johns 
Hopkins  Hospital.) 


respirations  become  somewhat  stertorous  and  more  rapid,  in- 
creasing to  possibly  36  or  40  per  minute ;  the  i^idse  starts  at  a 
little  above  the  normal  rate  and  increases  to  116  or  120  and  then 
drops  to  normal,  which  is  slightly  below  the  rate  at  which  it 
started;  the  color  is  normal  at  first  and  then  may  become  crim- 
son, or  it  may  change  very  little;  the  pupils  first  dilate,  and 
then  contract  almost  to  a  pin  point. 


294  OBSTETRICAL  NURSING 

Unfavorable  signs  are:  respirations  that  are  rapid  and  shal- 
low, then  possibly  slow,  but  still  shallow;  increasing  pulse  rate, 
this  being  so  serious  that  the  ether  is  usually  stopped  if  the  pulse 
approaches  140,  and  stimulation  is  promptly  given;  cyanosis 
which  is  slight  at  first  and  then  extreme,  and  dilated  pupils. 

It  is  obviously  not  wise  nor  possible  to  attempt,  by  means 
of  a  few^  paragraphs  and  illustrations  to  teach  a  nurse  so  tech- 
nical and  important  a  procedure  as  the  administration  of  an 
anesthetic,  but  it  is  hoped  that  these  general  suggestions  may  be 
helpful,  particularly  to  the  nurse  who  is  unexpectedly  confronted 
by  an  emergency. 

Under  all  conditions  the  nurse  must  remember  that  no  mat- 
ter what  anesthetic  is  given,  nor  by  whom  it  is  administered, 
she  must  guard  against  the  very  prevalent  tendency  to  talk  freely 
while  the  patient  is  going  under,  in  the  belief  that  she  is  un- 
aware of  what  is  going  on  about  her.  Many  patients  suffer 
great  mental  distress  because  of  hearing,  or  partly  hearing  con- 
versation not  intended  for  their  ears,  which  takes  place  in  their 
hearing  while  they  are  incompletely  anesthetized. 


CHAPTER  XIII 

OBSTETRICAL   OPERATIONS   AND   COMPLICATED 

LABORS 

Unhappily,  not  all  labors  run  the  smooth  and  uncomplicated 
course  which  was  described  in  the  last  chapter.  Certain  ab- 
normalities sometimes  arise  to  complicate  delivery,  occasionally 
necessitating  operative  interference  or  relief. 

There  is  little  that  a  nurse  can  do  alone,  in  the  presence 
of  complicated  labor,  but  her  preparations  and  assistance  will 
be  more  effective  if  she  understands  the  purpose  of  the  opera- 
tions, and  she  will  better  appreciate  the  gravity  of  cercain  symp- 
toms, which  she  is  required  to  watch  for  and  report,  if  she  real- 
izes the  extreme  seriousness  of  their  import. 

The  principal  conditions  which  give  rise  to,  or  follow  com- 
plications, prevent  spontaneous  delivery  or  necessitate  operations 
at  the  time  of  labor  are  perineal  lacerations ;  contracted  or  mal- 
formed pelves;  marked  disproportion  between  the  diameters  of 
the  child's  head  and  mother's  pelvis;  ruptured  uterus;  exhaus- 
tion of  the  mother ;  poor  muscle  tone  or  certain  chronic  and  acute 
diseases  of  the  mother ;  death  of  the  fetus ;  prolapsed  cord ;  cer- 
tain presentations  of  the  fetus  in  which  spontaneous  delivery  is 
doubtful  or  impossible. 

The  preparations  for  operations  in  hospitals  are  all  so  care- 
fully planned  and  systematized  that  in  the  presence  of  such 
emergencies  the  nurse  will  merely  have  to  carry  out  the  cus- 
tomary routine,  but  in  a  patient's  home  she  may  have  to  exercise 
a  good  deal  of  originality  in  attempting  to  meet  the  needs  of  the 
occasion  and  imitate  hospital  provisions. 

A  satisfactory  operating  table  may  be  fashioned  in  any  one 
of  a  number  of  ways.  If  the  bed  is  high  enough,  it  may  some- 
times be  made  fairly  satisfactory  by  slipping  a  board,  such  as  a 
cable  leaf,  under  the  mattress  to  make  it  firm.     The  use  of  a 

293 


296  OBSTETRICAL  NURSING 

kitchen  table  is  time-honored,  but  it  is  an  unsafe  practice  unless 
the  available  table  is  very  secure  and  firm,  which  is  usually  not 
the  case  with  present-day  kitchen  tables.  A  flat-topped  chest 
of  drawers,  with  the  casters  removed,  makes  an  excellent 
operating  table,  for  it  is  firm,  a  good  height  and  about  the  right 
size.  Or  an  ordinary  bureau  may  be  pressed  into  service  after 
taking  out  the  casters  and  removing  the  mirror  by  unscrewing 
its  supports.  The  front  and  sides  of  a  bureau,  or  chest  of 
drawers  so  used  should  be  protected  from  the  damaging  effects 
of  fluids  and  solutions  by  being  covered  with  a  bed-rubber  or 
newspapers.  A  pad  for  the  top  of  the  improvised  operating  table 
may  be  arranged  by  folding  a  blanket  or  quilt  to  the  proper  size 
and  folding  over  that  the  rubber  draw-sheet  and  a  clean  muslin 
sheet. 

If  the  operation  requires  that  the  patient  be  held  in  the 
lithotomy  position  (on  her  back  with  thighs  and  knees  flexed 
and  knees  well  separated),  and  the  doctor's  equipment  does  not 
include  a  strap  to  hold  the  legs,  one  may  be  improvised  from  a 
sheet.  It  should  be  folded  diagonally,  over  and  over,  into  a 
strip  possibly  a  foot  wide,  passed  over  one  shoulder  and  the 
tapering  ends  used  to  tie  around  the  legs,  above  the  knees,  to 
hold  them  in  the  desired  position.  Bandages  or  tapes  are  not 
always  satisfactory,  for  the  support  is  subject  to  a  good  deal 
of  strain,  and  narrow  strips  sometimes  cut  painfully  into  the 
legs  and  shoulders.  Certainly  if  tapes  or  bandages  are  used, 
cotton  pads  or  folded  towels  should  be  interposed  between  them 
and  the  patient's  skin. 

In  general,  the  nurse  will  prepare  as  for  a  normal  delivery, 
in  each  instance  adding  such  details  of  equipment,  or  preparation 
as  the  contemplated  operation  requires.  Rigid  asepsis  must  be 
observed  throughout  the  preparations  and  the  operations.  When 
large  instruments  or  appliances  are  to  be  used,  a  wash  boiler 
is  probably  the  safest  thing  in  which  to  boil  them,  for  it  is 
scarcely  possible  entirely  to  cover  them  with  water  in  a  smaller 
receptacle ;  and  they  must  be  well  covered  while  boiling,  or  they 
will  not  be  sterile. 

Perineal  Lacerations.  A  large  proportion  of  women  during 
the  birth  of  the  first  baby  sustain  some  degree  of  perineal  lacera- 


OBSTETRICAL  OPERATIONS  297 

tion,  which  may  amount  to  nothing  more  than  a  nick  in  tfte 
mucous  membrane,  or  it  may  extend  entirely  across  the  peri- 
neal body  and  tear  through  the  rectal  sphincter.  The  causes 
of  these  tears  are  generally  conceded  to  be  rigidity  of  the  perineal 
muscles;  disproportion  between  the  size  of  the  child's  head  and 
the  vulval  opening;  a  sudden  expulsion  of  the  child's  head,  be- 
fore the  perineum  is  fully  distended,  and  certain  abnormalities 
in  the  mechanism  of  labor.  Lacerations  may,  therefore,  be  pre- 
vented, or  limited,  in  many  cases  by  holding  back  the  baby's 
head  and  allowing  it  to  dilate  the  perineum  slowly.  But  in  spite 
of  the  most  skillful  and  careful  efforts,  tears  of  some  degree 
occur  in  most  primiparae,  and  probably  in  half  of  all  multipara. 
These  injuries  are  usually  described  as  being  of  the  first,  second 
or  third  degree,  according  to  their  extent. 

A  first  degree  tear  is  one  that  extends  only  through  the 
mucous  membrane,  usually  at  the  margin  of  the  perineum,  with- 
out involving  any  of  the  muscles. 

A  second  degree  tear  is  one  that  extends  down  into  the 
perineal  body  and  may  involve  the  levator  ani,  or  even  extend 
down  to,  but  not  through  the  rectal  sphincter.  Such  a  tear 
usually  extends  upward  on  one  or  both  sides  of  the  vagina  mak- 
ing a  triangular  injury. 

A  third  degree  tear  extends  entirely  across  the  perineal 
body  and  through  the  rectal  sphincter  and  sometimes  up  the 
anterior  wall  of  the  rectum.  This  variety  is  often  called  a 
complete  tear,  in  contradistinction  to  those  of  first  and  sec- 
ond degree,  which  are  incomplete. 

It  is  a  fairly  general  custom  to  repair  these  lacerations  at 
the  time  of  labor,  no  matter  what  their  extent,  the  sutures  being 
introduced  but  not  tied,  during  the  third  stage.  The  patient 
is  usually  sufficiently  anesthetized  to  permit  of  this,  without 
further  anesthesia,  in  all  but  complete  tears,  and  as  there  is 
usually  but  very  slight  bleeding  before  the  expulsion  of  the 
placenta,  the  field  is  comparatively  clear  and  the  stitches  are 
easily  put  into  place.  They  are  not  tied,  as  a  rule,  until  after 
delivery  of  the  placenta  because  of  the  strain  which  its  expul- 
sion would  put  upon  the  fresh  stitches.  In  all  but  very  slight 
tears,  the  doctor  will  usually  want  the  patient  turned  across  the 


298  OBSTETRICAL  NURSING 

bed,  with  her  hips  brought  to  the  edge,  and  her  legs  supported 
in  the  lithotomy  position.  As  the  few  instruments  necessary 
for  perineal  repairs  should  be  boiled  and  placed  in  readiness 
before  labor,  there  is  usually  no  further  preparation  for  the 
nurse  to  make,  and  the  perineal  dressing,  after  the  stitches  have 
been  taken,  is  ordinarily  the  same  as  that  following  a  normal 
delivery.     (See  Fig.  80  for  necessary  instruments.) 

Some  physicians  prefer  not  to  repair  perineal  tears  until 
some  days  after  labor,  contending  that  the  congestion  of  the 
soft  parts  immediately  after  delivery  is  not  favorable  to  a  satis- 
factory union.  When  the  repair  is  made  subsequently,  there- 
fore, the  nurse  prepares  as  she  would  for  any  perineal  opera- 
tion, performed  independently  of  labor.  Repairs  are  not  often 
postponed  for  more  than  a  few  days,  since  long  delayed  or 
neglected  attention  frequently  gives  rise  to  gynecological  dis- 
orders, such  as  descensus  or  prolapse  of  the  uterus. 

Episiotomy.  Some  obstetricians  prefer  to  anticipate  a  peri- 
neal tear  by  making  an  oblique  incision,  usually  on  one  or 
both  sides,  extending  downward  and  outward  from  the  margin 
of  the  vaginal  outlet  down  into  the  perineum.  This  operation 
is  termed  episiotomy,  and  the  incision  is  sutured  after  labor  just 
■as  a  tear  would  be.  It  is  the  belief  of  those  who  perform  this 
operation  that  the  clean-cut  incision  heals  more  satisfactorily 
than  an  irregular  tear,  and  that  by  directing  the  incision  to  the 
side,  away  from  the  median  line,  the  integrity  of  the  rectal 
sphincter  is  preserved,  even  though  the  perineum  tears  beyond 
the  end  of  the  incision,  when  distended  during  the  birth  of  the 
head. 

Breech  Extraction.  In  some  cases  of  breech  presentation, 
particularly  among  primipars,  it  is  necessary  to  assist  nature 
in  the  delivery  of  the  child  in  order  to  save  its  life.  Complete 
anesthesia  is  usually  necessary  at  such  times  and  the  jiatient  is 
preferably  on  a  table  or  at  the  edge  of  the  bed  in  a  lithotomy 
position. 

In  the  majority  of  cases,  no  effort  is  made  toward  assistance 
until  the  body  is  born  as  far  as  the  umbilicus,  partly  because  of 
the  difficulty  of  taking  hold  of  the  child  securely  before  that 
time,  and  partly  because  the  perineum  is  not  likely  to  be  fully 


OBSTETRICAL  OPERATIONS  299 

distended,  in  which  case  a  serious  tear  would  probably  result. 
But  after  the  body  has  been  extruded  as  far  as  the  umbilicus, 
it  is  usually  considered  imperative  to  complete  the  delivery 
within  eight  minutes  to  save  the  child  froi  asphyxiation,  due 
either  to  pressure  on  the  cord  between  the  head  and  pelvic  brim, 
or  to  premature  separation  of  the  placenta.  The  baby's  feet  or 
legs  are  grasped  by  a  towel  to  prevent  slipping,  and  downward 
traction  is  made  on  the  body  until  the  tips  of  the  scapulas  appear 
at  the  outlet.  During  this  procedure  the  nurse  may  be  called 
upon  to  make  pressure  on  the  uterus  with  the  idea  of  keeping 
the  baby 's  head  flexed  forward ;  preventing  the  arms  from  be- 
coming extended  upward  above  the  head  and  also  to  help  in 
expelling  the  child. 

After  the  scapula  appear,  the  arm  lying  posteriorly  is  brought 
down  over  the  chest  and  delivered.  The  body  is  then  rotated 
until  the  other  arm  lies  posteriorly  and  that  is  delivered.  After 
delivery  of  the  arms  and  shoulders  the  head  is  usually  delivered 
by  what  is  known  as  Mauriceau's  maneuver  as  follows:  The 
accoucheur  slips  the  index  finger  of  one  hand  into  the  vaginal 
outlet  and  into  the  child's  mouth,  and  supports  the  body  of 
the  child  upon  his  hand  and  forearm;  two  fingers  of  the  other 
hand  are  slipped  around  the  back  of  the  neck  and  curved  for- 
ward like  hooks  over  the  shoulders  and  strong  downward  trac- 
tion is  made  by  these  fingers ;  not  by  the  one  in  the  baby 's  mouth. 
The  occiput  emerges  from  beneath  the  symphysis,  after  which 
the  body  is  lifted  upward  and  the  chin,  nose,  forehead  and  entire 
head  are  born. 

Version.  By  version  is  meant  the  turning  of  the  child  within 
the  uterus  so  that  the  part  which  was  presenting  at  the  superior 
strait  is  replaced  by  another  part,  in  order  to  hasten  or  facilitate 
delivery.  It  is  usually  performed  as  the  patient  lies  flat  on  her 
back,  completely  anesthetized,  and  with  great  gentleness,  for 
fear  of  rupturing  the  uterus. 

Common  indications  for  a  version  are  a  transverse  presenta- 
tion; a  prolapsed  cord,  when  the  head  has  just  begun  to  enter 
the  superior  strait ;  and  in  some  cases  of  placenta  prtevia.  When 
the  fetus  is  so  turned  that  the  head  becomes  the  presenting  part, 
the  procedure  is  termed  a  cephalic  version;  if  so  turned  that 


300  OBSTETRICAL  NURSING 

the  breech  presents,  it  is  termed  a  podalic  version.  The  methods 
of  accomplishing  these  ends  are  described  as  external  version, 
if  the  turning  is  done  entirely  with  the  hands  working  through 
the  abdominal  wall;  internal  version  if  one  entire  hand  is  intro- 
duced into  the  uterine  cavity,  and  oomhined  version  when  one 
hand  is  outside  on  the  abdomen  and  two  fingers  of  the  other  are 
introduced  through  the  cervix  into  the  uterus. 

External  cephalic  version  is  often  performed  late  in  preg- 
nancy, or  early  in  labor,  in  transverse  and  also  in  breech  presen- 
tations, to  secure  a  vertex  presentation  because  of  the  high  fetal 
death  rate  in  breech  extractions.  Podalic  version,  or  making 
the  breech  the  presenting  part,  is  often  performed  in  trans- 
verse presentations,  in  placenta  prgevia  and  when  the  cord  or 
extremities  are  prolapsed.  Having  converted  the  presentation 
into  a  breech,  the  usual  breech  extraction  is  performed. 

Forceps  are  instruments  which  are  used  to  extract  the  child 
when  presenting  by  the  head  in  certain  conditions  which  en- 
danger the  life  of  mother  or  child.  The  value  of  forceps  in 
obstetrics  can  scarcely  be  overestimated,  as  before  their  invention 
the  only  operative  method  of  delivering  a  live  baby  was  by  means 
of  version  and  extraction,  and  in  these  the  fetal  death  rate  was 
high.  The  obstetrical  instruments  in  use  up  to  that  time,  there- 
fore, were  all  for  the  destruction  of  the  child  in  utero. 

Forceps  were  devised,  and  first  used,  in  great  secrecy,  early 
in  the  17th  century,  by  a  Dr.  Chamberlen,  in  England,  who  jeal- 
ously guarded  all  information  relating  to  his  invention  from 
every  one  but  members  of  his  own  family. 

There  were  several  doctors  in  the  Chamberlen  family  who 
practiced  obstetrics  and  who  used  these  forceps,  but  knowledge 
concerning  the  nature  of  the  instruments  and  methods  of  using 
them  was  not  shared  with  members  of  the  medical  profession 
outside  of  that  family,  until  the  beginning  of  the  18th  century. 
Since  that  time  the  use  of  forceps  has  been  widely  extended 
and  the  original  Chamberlen  instruments  have  been  so  modified 
and  altered  and  improved  by  different  obstetricians,  that  there  is 
now  a  bewildering  number  and  variety  in  existence  and  in  use. 
Probably  the  most  widely  used  are  those  which  were  devised  by 
Dr.  Tarnier  of  France  and  Dr.  Simpson  of  England,  respectively. 
(Fig.  107.)     The  Tarnier  instrument  is  known  as  an  axis  trac- 


OBSTETRICAL  OPERATIONS  301 

tion  forceps,  and  can  be  used  in  all  kinds  of  forceps  operations, 
while  Dr.  Simpson's  are  suitable  for  use  only  in  low  forceps 
cases. 

There  are  two  groups  of  indications  for  the  use  of  forceps; 
those  relating  to  the  condition  of  the  ciiild  and  those  relating 
to  the  motlier. 

Indications  for  their  use  in  the  interests  of  the  child  are 


Fig.  107. — T\vo  widely  used  forceps.     A,  Tarnier  axis-traction  forceps. 
B,  Simpson  forceps. 

symptoms  of  asphyxia,  and  these  are  the  passage  of  meconium, 
in  head  presentations,  and  a  change  in  the  rate  or  rhythm  of 
the  fetal  heartbeat.  As  pressure  on  the  abdomen  of  the  fetus 
during  labor,  in  breech  presentations,  is  veiy  likely  to  express 
meconium,  this  is  not  of  special  significance  in  these  cases.  But 
in  head  presentations,  the  escape  of  meconium  suggests  paralysis 
of  the  rectal  sphincter  muscles,  due  to  imperfect  oxygenation, 
which,  in  turn,  is  caused  by  interference  with  the  placental 
circulation  by  pressure  on  the  cord  or  premature  separation  of 
the  placenta. 

Conditions  which  menace  tlie  life  of  the  mother,  and  indicate 


302 


OBSTETRICAL  NURSING 


the  use  of  forceps,  are  inadequate  contractions  of  the  uterine 
and.  abdominal  muscles ;  exhaustion,  as  indicated  by  an  increase 
in  the  maternal  pulse  rate  or  elevation  of  temperature,  and  in 
certain  chronic  and  infectious  diseases,  when  the  patient  may 
be  unable  to  stand  the  strain  of  the  second  stage. 

Forceps  are  usually  employed  when  the  head  fails  to  make 
satisfactory  advancement  after  two  hours  of  good,  second-sta^ge 
pains,  or  when  it  remains  in  one  place  on  the  perineum  for  an 
hour,  in  spite  of  good,  second-stage  pains. 

Otherwise,  there  is  danger  of  necrosis  or  sloughing  of  the 


Fig.  108. — Patient  in  position  and  draped  for  forceps  operation. 
(From  photograiA  taken  at  Johns  Hopkins  Hospital.) 

soft  parts  as  a  result  of  pressure,  with  a  subsequent  recto-vaginal 
or  vesico-vaginal  fistula. 

Among  the  acute  conditions  in  which  forceps  are  indicated 
are  typhoid  fever ;  pneumonia ;  acute  edema  of  the  lungs,  hemor- 
rhage from  premature  separation  of  the  placenta;  intra-partum 
infection  and  eclampsia,  while  they  are  sometimes  used  in  such 
chronic  conditions  as  pulmonary  tuberculosis;  various  heart 
lesions,  particularly  when  there  is  broken  compensation. 

Before  appljnng  forceps  the  operator  will  usually  wish  to 
satisfy  himself  that  the  following  conditions  exist :  Complete 
dilatation  of  the  cervix,  otherwise  severe  lacerations  with  hemor- 


OBSTETRICAL  OPERATIONS 


303 


rhage  may  result ;  the  liead  must  have  entered  the  pelvis,  other- 
wise an  imperfect  application  of  the  forceps  may  result  in  death 
of  the  fetus  and  serious  injury  to  the  mother;  the  position  of 
the  child's  head  must  he  known  in  order  that  the  forceps  may 
be  properly  applied  over  the  ears;  the  membranes  must  have 
ruptured  or  the  forceps  may  slip. 

Forceps  operations  are  usually  desi^ated  as  being  high,  mid 
or  low,  depending  upon  the  level  to  which  the  head  has  de- 
scended into  the  pelvis.    If  the  head  is  at  the  superior  strait,  a 


Fig.  109. — Forceps  sheet  used  in  Fig.   108. 

high  forceps  operation  is  necessary ;  mid  forceps  if  the  head  is 
half  way  down  and  on  a  level  with  the  ischial  spines  and  low 
forceps  when  the  head  is  on  or  just  above  the  perineum. 

The  application  of  low  forceps  is  a  simple  operation  and  at- 
tended by  little  danger  to  mother  or  child ;  mid  forceps  is  more 
serious  and  high  forceps  is  very  serious  for  the  child  and  some- 
times for  the  mother. 

When  forceps  are  applied,  the  patient  must  be  at  the  edge 
of  the  bed  or  preferably  on  a  table,  in  the  lithotomy  position 
(Fig.  108),  and  completely  anesthetized.  She  should  be  shaved 
and  scrubbed  as  for  a  normal  delivery,  after  which  a  sterile 


304  OBSTETRICAL  NURSING 

towel  soaked  in  biehlorid  1-1,000  or  lysol  2  per  cent.,  is  placed 
over  the  vulva  and  allowed  to  remain  until  the  operation  is 
performed.  She  should  be  draped  with  sterile  leggings  and 
towels,  one  of  which  is  folded  over  the  centre  of  a  wide  strip 
of  adhesive  about  twenty  inches  long,  and  hung  curtain-like 
over  the  rectum  by  strapping  the  free  ends  to  the  buttocks  on 
each  side,  while  over  all  is  placed  a  sheet  with  three  openings; 
two  slits  for  the  legs  to  pass  through  and  one  rectangle  which 
exposes  the  field  of  operation,     (Figs.  109,  110.) 


Fig.  110. — Two  types  of  easily  made  leggings  suitable  for  use  during 
delivery  or  obstetrical  operations. 

Pubiotomy,  or  hebotomy,  consists  in  sawing  through  the 
pubic  bone  on  one  side  of  the  symphysis  with  a  string  or  Gigli 
saw.  This  operation  is  performed  in  some  cases  of  moderately 
contracted  and  funnel  pelves,  through  which  the  normal  ex- 
pulsive forces  of  labor  are  unable  to  force  the  child.  The 
separation  of  the  bone  allows  it  to  gape,  because  of  the  hinge- 
like movement  of  the  sacro-iliac  joint,  and  thus  the  superior 
strait  is  appreciably  widened  and  the  child  may  be 
delivered  by  high  forceps  or  version.  As  the  bone  heals  by 
fibrous  union,  there  is  sometimes  permanent  enlargement  of  the 


OBSTETRICAL  OPERATIONS  305 

pelvis  and  there  are  seldom  any  unsatisfactory  after-effects,  such 
as  impairment  of  locomotion.  Pubiotomy  is  sometimes  the  opera- 
tion decided  upon  when  a  patient  is  seen  for  the  first  time  after 
labor  is  well  advanced,  and  a  conservative  Caesarean  section  is 
thought  inadvisable  because  of  the  risk  of  infection.  But  the 
operation  is  becoming  more  and  more  rare,  for  the  general  prac- 
tice of  measuring  the  pelvis  and  supervising  patients  during 
pregnancy  discloses  serious  disproportions  early  enough  to  make 
a  Cesarean  section  the  elective  operation. 

Symphysiotomy.  This  operation  is  a  cutting  through  the 
cartilage  of  the  symphysis  pubis,  instead  of  through  the  pubic 
bone,  as  in  pubiotomy.  It  was  formerly  performed  for  much 
the  same  reasons  that  pubiotomy  is  now  used,  but  has  been  prac- 
tically abandoned  since  the  development  of  the  latter  operation. 
The  reasons  for  giving  it  up  were  that  the  close  proximity  of 
the  bladder  to  the  symphysis  resulted  in  frequent  injuries  to 
that  organ,  and  as  the  cartilage  of  the  symphysis  does  not  heal 
as  well  as  the  pubic  bone,  the  patients  frequently  experienced 
difficulty  in  walking  and  showed  a  tendency  to  tire  more  easily 
after  the  operation  than  before  it  was  performed. 

Vaginal  Hysterotomy,  or  vaginal  Caisarean  section,  as  it  is 
sometimes  called,  consists  of  incising  the  cervix  anteriorly  and 
posteriorly,  delivering  the  child  and  placenta  and  suturing  the 
wounds.  It  is  sometimes  performed  in  cases  which  for  some  rea- 
son require  immediate  delivery,  as  in  severe  cases  of  eclampsia. 
It  is  only  possible  when  the  relation  between  the  pelvis  and  the 
child's  head  is  such  as  to  permit  the  child  to  pass  through  the 
inlet.  It  is  rarely  done  in  primiparae,  because  rigidity  of  the 
outlet  prevents  proper  exposure ;  or  in  multiparas  at  term  as  the 
incisions  have  to  be  extended  so  high  to  deliver  a  term  baby,  that 
there  is  danger  of  tearing  the  lower  uterine  segment. 

Caesarean  Section  is  the  operation  by  means  of  which  the 
child  is  delivered  through  an  incision  in  the  abdominal  and 
uterine  walls.  It  is  believed  by  some  that  the  operation  was 
named  for  Julius  Caesar,  who  was  presumably  delivered  by  this 
method,  but  this  seems  scarcely  probable.  The  operation  was 
frequently  fatal  in  those  days  and,  moreover,  as  the  uterine  wall 
was  not  sutured  after  the  child  was  extracted,  a  woman  was  not 


306  OBSTETRICAL  NURSING 

likely  to  have  other  children  afterward  even  if  she  did  live,  and 
Cffisar's  mother  had  several  children  after  he  was  born.  An- 
other explanation  for  the  name  is  that  during  Caesar's  reign  a 
law  was  passed  which  required  that  the  abdomen  be  opened  and 
the  child  extracted  in  every  case  in  which  a  woman  died  late 
in  pregnancy,  as  one  means  of  increasing  the  population. 

Thus  it  will  be  seen  that  the  operation  itself  is  very  ancient, 
but  as  performed  to-day  it  embodies  the  most  modern  and  scien- 
tific knowledge  and  methods.  The  usual  indications  for  it  are 
cases  of  contracted  or  deformed  pelves;  cases  of  tumors  which 
block  the  birth  canal  or  when  very  speedy  delivery  is  imperative 
as  in  some  cases  of  eclampsia. 

The  anatomical  indications  for  Cesarean  section  are  depen- 
dent upon  the  degree  and  character  of  the  pelvic  contractions 
and  upon  the  size  and  mouldability  of  the  child's  head  in  rela- 
tion to  the  pelvis.  This  explains  why  in  two  women  with  pelves 
of  the  same  size  and  shape,  one  will  have  a  spontaneous  delivery 
and  one  will  require  a  section.  The  former  has  a  relatively  small 
child  which  can  pass  through  her  pelvis;  while  the  second 
woman's  baby  is  too  large,  or  the  head  not  sufficiently  mould- 
able,  to  pass  through  hers. 

This  is  one  exemplification  of  the  great  importance  of  pelvim- 
etry and  of  constant  watching  during  pregnancy,  for  the  best 
results  from  Cesarean  section  are  obtained  when  it  is  recognized 
that  spontaneous  delivery  is  unlikely  or  impossible;  the  opera- 
tion accordingly  is  performed  at  a  time  which  is  deliberately 
selected  by  the  obstetrician.  The  elected  time  is  often  about  two 
weeks  before  the  expected  date  of  confinement  in  order  that  the 
baby  may  have  the  longest  possible  intra-uterine  life  and  that 
the  operation  may  be  performed  before  the  patient  goes  into 
labor.  In  these  cases  in  which  it  is  known  that  a  section  is  to 
be  performed  vaginal  examinations  are  omitted  after  the  pelvic 
measurements  are  taken,  in  order  to  minimize  the  possibilities 
of  infection,  this  being  one  of  the  great  risks  of  the  operation. 

Until  recent  years  the  operation  was  usually  delayed  until 
after  the  patient  had  been  vaginally  examined,  had  been  in  labor 
long  enough  to  be  exhausted  and  the  only  other  courses  open 
were  high  forceps  or  a  destructive  operation  upon  the  child.   The 


OBSTETRICAL  OPERATIONS  307 

results  of  the  operation  undertaken  under  such  circumstances 
were  not  good,  and  the  maternal  deaths  from  infection  were  so 
frequent  that  the  operation  on  the  whole  was  very  hazardous. 
But  improved  surgical  technique  and  extended  knowledge  of 
the  pelvis  have  so  revolutionized  Caesarean  section  that  it  is  now 
successful  in  the  majority  of  cases. 

There  are  three  main  types  of  Caisarean  section :  conservative, 
radical  and  extraperitoneal. 

The  conservative  operation  consists  of  opening  the  abdomen 
in  the  mid-line;  incising  the  uterus;  extracting  the  child  and 
placenta,  and  suturing  both  uterine  and  abdominal  walls.  This 
is  the  usual  operation  when  there  is  a  choice,  but  because  of  the 
danger  of  infection,  it  is  ordinarily  performed  only  before  the 
onset  of  labor  or  in  the  early  part  of  the  first  stage,  and  many 
obstetricians  are  loath  to  undertake  it  then  if  the  patient  has 
been  examined  vaginally,  particularly  if  the  technique  of  the 
examination  was  open  to  question. 

In  the  radical  oi)eration  the  abdomen  and  uterus  are  incised ; 
the  child  and  i)lacenta  extracted  and  the  uterus  is  amputated 
just  above  the  cervix.  This  operation  is  usually  performed  when 
labor  is  well  advanced  and  there  is  fear  of  infection. 

In  the  extraperitoneal  operation  the  incision  in  the  abdomen 
is  made  low  down  on  one  side,  the  peritoneum  is  not  incised 
but  is  peeled  back  from  tlie  bladder  and  lower  part  of  the  uterus. 
The  uterus  may  thus  be  opened  and  the  child  and  placenta  ex- 
tracted, without  entering  the  peritoneal  cavity,  thereby  greatly 
reducing  the  risk  of  infection,  and  also  without  necessitating  the 
removal  of  the  uterus  as  a  safeguard  against  infection.  This 
operation,  also,  is  performed  late  in  labor  when  infection  is  feared, 
but  is  considered  very  difficult  and  tlierefore  is  not  common. 

The  nurse's  duties  in  connection  with  a  Ca^sarean  section  are 
the  same  as  those  in  any  abdominal  operation  plus  preparations 
for  receiving  and  reviving  the  baby. 

A  Ruptured  Uterus  is  a  splitting  of  the  uterine  wall  at 
some  point,  usually  in  the  lower  uterine  segment,  that  has  be- 
come thinned  or  weakened  and  unable  to  stand  the  strain  of  fur- 
ther stretching  incident  to  uterine  contractions,  and  is  accom- 
panied by  an  extrusion  of  all  or  a  part  of  the  uterine  contents 


308  OBSTETRICAL  NURSING 

into  the  abdominal  cavity.  The  rupture  of  a  uterus  during  labor 
is  a  very  rare  accident,  occurring  but  once  in  from  500  to  1,000 
cases  and  usually  only  in  prolonged  labors,  obstructed  labors  or 
certain  faulty  presentations.  It  is  also  a  very  grave  accident, 
since  the  baby  nearly  always  dies  and  sometimes  the  mother  as 
well. 

The  cause  of  a  ruptured  uterus  mry  be  found  in  scar  tissue, 
following  a  CECsarean  section  or  an  injury;  inherent  defects  in 
the  tissues  comprising  the  uterine  wall;  contracted  pelves;  neg- 
lected transverse  presentations  and  the  accident  may  occur 
during  a  version.  It  is  usually  preceded  by  extreme  tenderness 
in  the  lower  uterine  segment,  the  part  that  is  being  abnormally 
stretched.  The  common  symptoms,  after  the  rupture  has  oc- 
curred, are  sudden  and  acute  abdominal  pain  during  a  contrac- 
tion, which  the  patient  describes  as  being  unlike  anything  she 
has  ever  felt  and  as  though  "something  had  given  way"  inside 
of  her.  There  is  immediate  and  complete  cessation  of  labor 
pains  because  the  torn  uterus  no  longer  contracts.  Sooner  or 
later  the  patient  has  sj^mptoms  of  shock  because  of  the  hemor- 
rhage, which  is  usually  internal,  though  there  may  be  vaginal 
bleeding  as  well.  Her  face  becomes  pale  and  drawn  and  covered 
with  perspiration ;  her  pulse  is  weak  and  rapid ;  she  appears  ex- 
hausted and  collapsed  and  may  complain  of  chilly  sensations 
and  air  hunger. 

Abdominal  palpation  shows  that  the  lower  uterine  segment  is 
even  more  sensitive  than  formerly  and  that  the  presenting  part 
has  slipped  away  from  the  superior  strait  while  at  the  side  of  the 
fetus  the  contracted  uterus,  partly  or  entirely  empty,  may  be 
felt  as  a  hard  mass.  The  symptoms  of  shock  may  be  delayed  for 
some  time  when  they  will  be  accompanied,  as  a  rule,  by  abdom- 
inal distension,  due  to  hemorrhage,  and  a  slight  elevation  of 
temperature. 

The  prevention  of  this  disaster  lies  in  performing  version  and 
prompt  extraction  in  transverse  presentations,  as  soon  as  the 
cervix  is  dilated,  and  in  interference  if  the  presenting  part  does 
not  engage  after  an  hour  of  strong,  second-stage  pains. 

The  treatment  of  a  ruptured  uterus  is  influenced  by  many 
factors.    Possibly  the  most  frequent  course  followed  is  to  open 


OBSTETRICAL  OPERATIONS  309 

the  abdominal  cavity  and  repair  or  remove  the  uterus,  after 
extracting  the  fetus  and  placenta,  according  to  existing  condi- 
tions and  the  jndgment  of  the  operator.  Sometimes  the  fetus  is 
removed  through  tlie  vagina  and  the  uterus  repaired  through 
that  channel. 

Destructive  Operations  have  as  their  purpose  the  crush- 
ing or  dismembering  of  the  child  in  utero  so  that  it  may  pass 
through  the  pelvis.  In  the  early  days  such  operations  were  re- 
sorted to  fairly  often  in  the  presence  of  conditions  that  threat- 
ened the  mother's  life  and  which  apparently  could  not  be  met  in 
any  other  way.  They  are  performed  less  and  less  frequently 
to-day  because  of  the  success  attending  the  performance  of  Cae- 
sarean  section,  version,  pubiotomy  and  forceps  operations.  They 
are  never  sanctioned  by  the  Catholic  Church  in  cases  where  the 
child  is  alive. 

Induced  Abortions  and  Premature  Labors.  As  was  ex- 
plained in  the  chapter  on  complications  and  accidents  of  preg- 
nancy, it  is  sometimes  deemed  advisable,  or  necessary  to  term- 
inate pregnancy  by  artificial  means,  in  the  interests  of  the  mother 
or  child  or  both. 

The  procedures  are  termed  induced  abortion,  induced  prema- 
ture labor  and  accouchement  force.  The  effects  of  these  opera- 
tions, per  se,  when  skillfully  performed,  for  therapeutic  pur- 
poses, are  not  usually  considered  more  serious  for  the  mother 
than  a  normal  delivery,  since  they  can  be  performed  with  delib- 
erate care  and  cleanliness  and  can  be  followed  by  adequate  after- 
care. When  the  reverse  conditions  prevail,  as  in  criminal  abor- 
tions, the  patient's  subsequent  suffering  or  ill  health  are  more 
likely  to  be  due  to  the  poor  obstetrics  and  unclean  work  which 
is  characteristic  of  practitioners  who  are  willing  to  do  illegal 
operations,  than  to  the  termination  of  pregnancy  itself.  It  is 
important  that  the  nurse  fully  appreciate  this  and  be  as  scrupu- 
lously careful  in  her  preparations  for,  and  assistance  with  these 
operations  as  for  a  major  operation  or  a  normal  delivery. 

Induced  abortion  applies  to  the  termination  of  pregnancy 
before  the  child  is  viable,  or  before  the  end  of  the  twenty-eighth 
week,  and  is  performed  solely  in  the  interests  of  the  mother,  as 
the  fetus  is  always  lost.     It  is  resorted  to  in  those  cases  where 


310  OBSTETRICAL  NURSING 

the  mother  is  suffering  from  some  condition,  which  may  or  may 
not  be  inherent  to  pregnancy,  which  threatens  her  life  or  health 
but  which  it  is  believed  may  be  cured  or  arrested  if  uncompli- 
cated by  pregnancy.  Such  conditions  may  be  toxemic  vomiting; 
nephritis,  particularly  with  evidences  of  increasing  renal  insuf- 
ficiency; bleeding,  due  to  an  incomplete  abortion;  a  dead  fetus; 
infection  following  an  attempt  at  criminal  abortion.  Contracted 
pelves  and  pulmonary  tuberculosis  are  sometimes  taken  as  indi- 
cations for  inducing  abortions,  but  with  the  development  and 
improvement  of  obstetrical  operations,  more  and  more  women 
are  able  to  go  nearly,  or  quite,  to  term  and  be  delivered  of  live 
babies;  while  increasing  medical  knowledge  concerning  the  care 
of  patients  with  tuberculosis,  and  also  with  some  heart  lesions, 
is  applied  so  successfully  during  the  prenatal  period  that  some 
pregnancies  which  formerly  would  have  been  terminated,  are  now 
allowed  to  continue,  and  with  happy  results. 

The  methods  of  induction  depend  upon  the  stage  to  which 
pregnancy  has  advanced  and  also  upon  the  importance  of  haste. 
In  the  very  early  stages,  one  method  is  for  the  operator  to  dilate 
the  cervix  with  a  dilator;  insert  one  finger  into  the  cervix  and 
up  into  the  uterus  and  separate  the  placenta  from  its  uterine  at- 
tachment, while  making  pressure  on  the  uterus  from  above  with 
the  other  hand  on  the  abdomen.  Another  method  is  to  introduce 
a  gauze  pack  into  the  cervix,  packing  it  and  the  vagina  firmly 
and  leaving  the  packing  for  twenty-four  hours.  When  it  is  re- 
moved the  ovum  frequently  follows.  Sometimes  the  membranes 
are  ruptured,  after  which  the  amniotic  fluid  drains  off  and  the 
ovum  is  expelled ;  or  vaginal  hysterotomy  is  sometimes  performed 
when  the  patient's  condition  is  such  that  haste  is  imperative. 
The  termination  of  pregnancy  before  viability  is  never  sanctioned 
by  the  Catholic  Church,  because  of  the  almost  certain  loss  of  the 
child. 

Induction  of  premature  labor.  This  procedure  is  the  ter- 
mination of  pregnancy  after  the  twenty-eighth  week,  or  after 
the  child  is  viable,  and  may  be  performed  to  save  either  the 
mother  or  the  child  or  both,  from  conditions  which  would  evi- 
dently work  destruction  if  allowed  to  persist.  The  indications 
for  inducing  labor  prematurely  may   he  a  seriously  overtaxed 


OBSTETRICAL  OPERATIONS 


311 


heart  or  kidneys ;  pulmonary  tuberculosis ;  preeclamptic  toxemia 
or  nephritic  toxemia ;  chorea,  neuritis ;  pyelitis ;  placenta  prasvia ; 
a  fetus  that  has  been  dead  for  two  weeks,  with  no  signs  of  labor; 
in  some  cases  of  nephritis  when  the  fetus  during  previous  preg- 
nancies has  died,  and  it  is  believed  that  the  child  may  be  saved 
by  inducing  labor  before  the  stage  in  pregnancy  at  which  the 
others  perished. 

Labor  is  sometimes  induced  when   the  mother's  pelvis  is 


Fig.  111. — Kubber  bougie  used  in  inducing  labor, 

normal,  but  the  child  has  grown  as  large  as  is  safe  in  anticipa- 
tion of  a  spontaneous  labor,  and  particularly  if  the  expected 
date  of  confinement  has  passed. 

A  common  method  of  inducing  labor  when  haste  is  not  im- 
portant, is  to  introduce  one  or  more  bougies  (Fig.  Ill)  through 
the  cervix  into  the  uterine  cavity  between  the  membranes  and 
the  uterine  wall.    The  presence  of  the  bougies  will  often  stimu- 


FiG.  112. — Champetier  de  Eibes'  bag. 


late  the  uterine  contractions  and  bring  on  labor,  with  expulsion 
of  the  fetus,  in  from  six  to  twenty-four  hours. 

More  speedy  results  are.  obtained  by  the  use  of  rubber  bags, 
which  may  be  collapsed  before  introduction  and  expanded  after- 
ward by  filling  them  with  sterile  salt  solution.  There  is  a  great 
variety  of  bags  for  this  purpose,  two  of  which  that  are  frequently 
used  are  the  Champetier  de  Ribes  (Fig.  112)  and  the  Voorhees 


312 


OBSTETRICAL  NURSING 


bags.     (Fig.  113.)     They  come  in  graduated  sizes,  the  largest 
holding  about  500  cubic  centimetres. 

The  operation  is  performed  with  the  patient  in  the  dorsal 


Fig.  113. — ^Voorhees'  bag,  collapsed. 

position.  The  cervix  is  drawn  down  into  sight,  with  forceps,  and 
if  intact,  is  slightly  dilated.  The  bag  is  rolled  tightly,  held  in 
suitable  forceps  (Fig.  114),  and  after  being  well  lubricated  is 


Fig.   114. — Eubber  bag  rolled   and  held   in  forceps  for   introduction 
into  uterus. 

introduced  through  the  slightly  dilated  cervix  into  the  lower 
uterine  segment,  and  pumped  full  of  sterile  salt  solution.  The 
solution  is  first  measured  in  order  to  be  sure  that  the  bag  is 
filled  to  its  desired  capacity,  and  is  then  introduced  by  means 


FiQ.  115. — Syringe  for  introducing  sterile  water  into  bag  after  its  in- 
sertion into  the  uterus. 


OBSTETRICAL  OPERATIONS  313 

of  a  syringe,  (Fig.  115),  through  the  rubber  tubing  which  is 
attached  to  the  lower  end  of  the  bag,  and  which  is  then  closed 
off  by  the  stop  cock,  to  prevent  escape  cf  the  fluid.  It  is  very  im- 
portant that  the  solution  be  sterile  in  view  of  the  possibility  of 
any  rubber  bag  rupturing,  particularly  when  pressed  upon  by 
the  contracting  uterus.  (Sec  Fig.  47  for  position  of  bag  after 
introduction  into  uterus.) 

The  presence  of  this  bag  stimulates  uterine  contractions,  the 
cervix  dilates,  the  bag  is  expelled  and  in  some  instances  the  child 
is  delivered  spontaneously  and  in  others  by  means  of  forceps. 
The  effect  of  this  bag  in  producing  labor  may  be  hastened  by 
tying  a  weight  to  the  end  of  the  tubing  and  allowing  it  to  hang 
over  the  side  of  the  bed.  This  traction  and  pressure  help  to 
dilate  the  cervix  and  seem  to  increase  the  irritation  of  the  uterine 
muscles,  thus  increasing  the  force  of  their  contractions. 

Accouchement  force  is  a  speedy,  forced  delivery  requiring 
the  forcible  widening  of  an  intact,  or  partly  dilated  cervix, 
manually,  or  instrumentally.  It  is  sometimes  performed  when 
existing  conditions  require  extreme  haste,  as  in  certain  heart 
lesions;  eclampsia;  concealed  or  accidental  hemorrhage  or  in 
any  condition  which  suddenly  arises  to  threaten  the  life  of  the 
patient  or  her  expected  baby.  But  as  the  shock  of  this  operation 
is  great  and  the  condition  which  threatens  the  patient  can  usu- 
ally be  better  relieved  by  means  of  some  one  of  the  operations 
already  described,  it  is  less  and  less  frequently  performed. 


THE  MIRACLE* 
by 

Elizabeth  Newport  Hepburn 

The  wind  blows  down  the  street, 

A  shutter  bangs  somewhere, 
While  twilight  falls  as  softly  as 

A  woman's  flowing  hair. 

Within  a  quiet  room, 

Adventurers  at  rest, 
A  mother  holds  her  newborn  son, 

Safe,  now,  upon  her  breast ! 

For  out  of  Night  and  Pain, 

The  womb  of  mystery, 
Is  sprung  this  miracle  of  Life 

That  she  can  touch  and  see. 

No  seer's  prophetic  dream, 

No  star  in  all  the  skies 
Burns  with  a  lustre  half  so  bright 

As  happy  mother  eyes. 

No  quester  for  the  Grail, 

No  searcher  for  the  Truth, 
Counts  more  than  those  who  bear  and  rear 

And  love  and  nurture  Youth ! 

Within  her  curving  arm, 

All  safe  and  warm  he  lies. 
The  heir  of  all  that  Man  has  won 

Down  countless  centuries ! 

*  Written  especially  for  this  book. 


PART  V 
The  Young  Mother 

CHAPTEE  XIV.  THE  PUERPERIUM.  Physiology.  Involution.  After 
pains.  Lochia.  Loss  of  Weight.  Menstruation.  Lactation.  Ab- 
dominal Wall.     Digestive  Tract.    Temperature.    Pulse.    Skin.     Urine. 

CHAPTER  XV.  ROUTINE  NURSING  CARE  DURING  THE  PUER- 
PERIUM. Complications  to  be  Guarded  against.  General  Treat- 
ment of  the  Patient.  Nursing  Care.  Position  in  Bed.  Sitting  up. 
The  Daily  Bath.  Diet.  The  Bowels.  The  Bladder.  Catheterization. 
Temperature,  Pulse,  and  Respiration.  Care  of  the  Perineum.  Care 
of  the  Breasts.  Lactation.  Stripping.  Abdominal  Binders  and 
Bed  Exercises. 

CHAPTER  XVI.  THE  NURSING  MOTHER.  Normal  Routine.  The 
Establishment  of  Breast  Feeding.  The  Mother's  Frame  of  Mind 
and  State  of  Nutrition.  Method  of  Nursing.  The  Nursing  Schedule. 
Personal  Hygiene  of  the  Nursing  Mother.  Diet.  Bowels.  Rest 
and   Exercise.     Recreation.     Weaning.     Drying   up   the   Breasts. 

CHAPTER  XVII.  NUTRITION  OF  THE  MOTHER  AND  HER  BABY. 
Importance  of  Adequate  Nutrition  in  First  Weeks  of  Life.  Neces- 
sary Elements  of  an  Adequate  Dietary.  "Vitamines. "  Danger  of 
Deficiency  Diseases.  Danger  of  Conditions  Approaching  Recognizable 
Disease.  The  Deficiency  Diseases.  Scurvy.  Infantile  Scurvy,  Cor- 
rective Diet.  Beriberi.  Xeropthalmia.  Pellagra.  Rickets.  Cor- 
rective Diet.  Application  of  Principles  of  Nutrition  to  the  Diet  of 
the  Nursing  Mother. 

CHAPTER  XVIII.  COMPLICATIONS  OF  THE  PUERPERIUM.  Post- 
partum Hemorrhage.  Causes,  Treatment  and  Nursing  Care.  Puer- 
peral Infection.  History  of  Disease.  Prevention.  Symptoms,  Treat- 
ment and  Nursing  Care.  Phlegmasia  alba  dolens,  or  ' '  Milk  leg. ' ' 
Puerperal  Mania. 


CHAPTER  XIV 
THE  PHYSIOLOGY  OF  THE  PUERPERIUM 

The  puerperium  ^  is  ordinarily  regarded  as  comprising  the 
five  or  six  weeks  immediately  following  delivery.  During  this 
period  the  mother's  body  undergoes  various  changes  which  re- 
store it  very  nearly  to  its  pre-pregnant  state,  leaving  the  patient 
in  a  normal,  healthy  condition.  The  most  important  of  these 
changes  are  involution  of  the  uterus,  loss  of  weight  and  improve- 
ment in  tone  of  the  abdominal  and  perineal  muscles.  The  altera- 
tions which  produce  this  restoration  are  normal  physiological 
processes,  but  mismanagement  or  lack  of  care  while  they  are 
taking  place  may  result  in  serious  complications;  these  may  be 
immediate  or  remote,  such  as  hemorrhage  and  infection  or 
chronic  invalidism. 

Recognition  of  these  dangers,  and  the  possibility  of  prevent- 
ing them,  is  responsible  for  the  present  custom  of  obstetricians 
to  watch  over  their  patients  during  the  puerperium.  This  is  in 
sharp  contrast  to  the  old  practice  of  the  doctor's  visiting  the 
puerperal  woman  only  when  there  was  a  complication  so  ap- 
parent that  he  was  summoned. 

The  precautions  and  the  care  which  the  doctor  takes  of  his 
patient  after  delivery  involve  intelligent  and  watchful  nursing. 
In  order  to  give  this  the  nurse  must  understand  something  of 
the  normal  physiology  of  the  puerperium,  just  as  she  did  in 
pregnancy  and  labor.  Otherwise  she  may  not  be  able  to  dis- 
tinguish evidences  of  normal  changes  from  symptoms  of  com- 
plications. 

Involution.  Considerable  attention  is  centred  in  the  re- 
markable atrophic  changes  that  take  place  in  the  uterus  during 
the  puerperium,  for  it  is  upon  their  being  normal  that  the  pa- 
tient's recovery  and  future  well-being  so  largely  depend.     Im- 

*  From  pu^r,  child,  and  parere,  to  bring  forth. 

317 


318  OBSTETRICAL  NURSING 

mediately  after  delivery  the  uterus  weighs  about  two  pounds ;  is 
from  seven  to  eight  inches  high ;  about  five  inches  across  and 
four  inches  thick.  The  top  of  the  fundus  may  be  felt  above  the 
umbilicus,  and  the  inner  surface,  wiiere  the  placenta  was  at- 
tached, is  raw  and  bleeding.  At  the  end  of  six  or  eight  weeks  the 
uterus  has  descended  into  the  pelvic  cavity  and  resumed  ap- 
proximately its  original  position  and  size,  and  its  former  weight 
of  two  ounces ;  a  new  lining  has  developed  from  the  few  glands 
which  have  not  been  cast  off  in  the  discharges. 

This  rapid  diminution  in  the  size  of  the  uterus  is  termed 
involution  and  is  accomplished  by  means  of  a  process  of  self- 
digestion  or  autolysis.  The  protein  material  in  the  uterine  walls 
is  broken  down  into  simpler  components  which  are  absorbed  and 
eventually  cast  off  largely  through  the  urine.  This  change  and 
absorption  of  uterine  tissues  is  similar  to  the  resolution  that 
takes  place  in  a  consolidated  lung  in  pneumonia. 

Since  satisfactory  involution  is  necessary  to  the  patient's 
future  health,  its  progress  should  be  watched  with  deep  concern 
and  interest,  and  all  possible  effort  made  to  promote  it ;  firm  con- 
sistency of  the  uterus  and  a  steady  descent  into  the  pelvis  and 
normal  lochia  being  the  chief  evidences  of  satisfactory  involu- 
tion. There  is  evidently  a  close  relation  between  the  functions 
of  the  breasts  and  of  the  uterus  during  the  puerperium,  and  as  a 
rule  involution  accordingly  progresses  more  normally  in  women 
who  nurse  their  babies  than  in  those  wdio  do  not. 

The  so-called  "after-pains"  are  also  affected  by  nursing,  be- 
ing more  severe  as  a  rule  Avhen  the  baby  is  at  the  breast  than  at 
other  times.  These  pains  are  caused  by  the  alternate  contrac- 
tions and  relaxations  of  the  uterine  muscles  and  are  more  com- 
mon in  multiparae,  than  in  primipar^e,  because  the  muscles  of 
the  former  have  somewhat  less  tone  than  the  latter  and  therefore 
tend  to  relax,  and  then  contract,  whereas  the  better  muscle  tone 
of  the  primipara  tends  to  keep  the  uterus  steadily  contracted. 

These  after  pains  usually  subside  after  the  first  twenty-four 
hours,  though  they  may  persist  for  three  or  four  days.  They 
may  amount  to  little  more  than  discomfort,  but  not  infrequently 
are  so  severe  as  to  require  the  administration  of  sedatives.  Per- 
sistent after  pains  may  be  due  to  retained  clots. 

The  cervix,  vagina  and  perineum  which  have  become  stretched 


THE  PHYSIOLOGY  OP  THE  PUERPERIUM       319 

and  swollen  during:  labor,  gradually  regain  their  tone  during 
the  puerperiuni,  and  the  stretched  uterine  ligaments  become 
shorter  as  they  ret-over  their  tune,  finally  regaining  their  former 
state.  Until  the  ligaments  and  the  pelvic  floor  and  abdominal 
wall  are  restored  to  normal  tonicity  the  uterus  is  not  adequately 
supported  and  tiierefore  may  be  easily  displaced. 

The  lochia  c(msists  of  the  uterine  and  vaginal  secretions  and 
the  blood  and  uterine  lining  which  are  cast  off  during  the  puer- 
periuni. During  the  first  three  or  four  days  tliis  discharge  is 
bright  red,  consisting  almost  entirely  of  blood,  and  is  termed 
the  lochia  rubra.  As  the  color  gradually  fades  and  becomes 
brownish  it  is  called  the  lochia  serosa.  After  about  the  tenth  day, 
if  involution  is  normal,  the  discharge  is  whitish  or  yellowish  and 
is  designated  as  the  lochia  alba.  The  total  amount  of  the  lochial 
discharge  has  been  variously  estimated  at  from  one  to  three  pints, 
being  more  profuse  in  multiparsB  than  primiparae,  and  in 
women  who  do  not  nurse  their  babies.  Under  normal  conditions 
the  discharge  is  profuse  at  first,  gradually  diminishing  until  it 
entirely  disappears  by  the  end  of  the  puerperium.  There  may 
be  small  amounts  of  blood  retained  during  the  first  day  or  two 
and  expelled  later  as  clots,  without  any  serious  significance,  and 
there  may  be  a  pinkish  discharge  after  the  patient  gets  up  for 
the  first  time,  but  if  the  lochia  is  persistently  blood-tinged  it 
may  be  taken  as  an  indication  that  the  uterus  is  not  involuting 
as  it  should. 

The  normal  characteristic  odor  is  flat  and  stale.  A  foul  odor, 
no  odor  at  all  or  a  marked  decrease  in  the  amount  of  the  dis- 
charge is  suggestive  of  infection. 

Loss  of  Weight.  One  of  the  striking  changes  during  the 
puerperium  is  the  loss  in  weight,  due  largely  to  three  factors: 
the  elimination  of  fluids  from  the  edematous  tissues;  the  de- 
crease in  the  size  of  the  uterus  and  the  escape  of  vaginal  and 
uterine  secretions,  termed  the  lochia.  The  smaller  amount  of 
food  taken  during  the  first  few  days  post-partum  also  may  be 
a  factor. 

This  loss  in  weight  is  extremely  variable,  fat  women  natu- 
rally losing  more  than  thin  women  and  those  who  nurse  their 
babies  losing  more  than  those  who  do  not. 

Dr.  Edgar  estimates  that  the  loss  through  the  lochia  amounts 


320  OBSTETRICAL  NURSING 

to  something  over  three  pounds,  and  the  loss  through  fluids  from 
the  tissues,  from  nine  to  ten  pounds.  According  to  Dr.  Slemons, 
the  loss  in  fluids  equals  about  1/lOth  of  the  patient's  weight  at 
the  beginning  of  the  puerperium,  while  all  agree  that  the  uterus 
decreases  about  two  pounds  in  weight.  All  told,  then,  the  patient 
may  normally  lose  from  twelve  to  fifteen  pounds  during  the 
puerperium.  This  loss  may  be  somewhat  controlled,  however,  by 
a  suitable  diet,  and  under  most  conditions  the  patient  should  re- 
turn to  not  less  than  her  pre-pregnant  weight  by  the  end  of  the 
sixth  or  eighth  week. 

Menstruation.  Although  in  the  ideal  course  of  events,  the 
mother  does  not  menstruate  while  nursing  her  baby,  that  is,  for 
eight  to  ten  months.  Dr.  Slemons  estimates  that  about  one-third 
of  all  nursing  mothers  begin  to  menstruate  about  two  months 
after  delivery,  while  according  to  Dr.  Edgar  one-half  of  those 
who  do  not  nurse  their  babies  begin  to  menstruate  in  six  weeks 
after  delivery. 

Menstruation  is  more  likely  to  return  early  in  primiparae 
than  in  multipai'aB.  Patients  sometimes  wonder  whether  this 
early  discharge  is  menstrual  or  lochial,  and  though  they  can  not 
tell,  a  physician  can  easily  decide  by  examination,  and  it  is  im- 
portant that  he  be  given  the  opportunity  to  do  so.  A  nursing 
mother  may  menstruate  once  and  then  not  again  for  several 
months  or  a  year;  or  she  may  menstruate  regularly  and  nurse 
her  baby  satisfactorily  at  the  same  time,  though  menstruation  is 
usually  regarded  as  unfavorable  to  lactation. 

Lactation.  During  the  first  two  or  three  days  after  the 
baby  is  born,  the  breasts  secrete  a  small  amount  of  yellowish 
fluid  called  colostrum,  which  differs  from  milk  chiefly  in  that 
it  contains  less  fat  and  more  salts  and  serum-albumen  than  milk 
and  in  the  fact  that  it  coagulates  upon  boiling.  About  the  third 
day  after  delivery,  the  meagre  amount  of  colostrum  is  replaced 
by  milk  and  as  it  increases  rapidly  in  amount,  the  breasts  usually 
become  tense  and  swollen  at  this  juncture,  and  sometimes  very 
painful;  but  this  turgidity  usually  subsides  after  a  day  or  two. 

The  function  of  the  breasts,  that  of  secreting  milk,  is  defi- 
nitely stimulated  by  the  baby's  suckling  and  will  not  continue 
for  more  than  a  few  days  without  this  stimulation,  a  fact  to  be 
remembered  if  it  is  desirable  for  any  reason  to  dry  up  the  breasts. 


THE  PHYSIOLOGY  OF  THE  FUERPERIUM       321 

The  ideal  condition  is  for  the  breasts  to  secrete  a  quantity 
and  quality  of  milk  which  will  adequately  nourish  the  baby  for 
eight  or  ten  months.  The  reverse  of  this  condition  is  sometimes 
found  in  very  young  or  in  elderly  women,  or  in  very  fat  or  frail, 
undernourished  women. 

Ovulation  is  usually  suspended  during  lactation,  but  a  mother 
may  become  pregnant  a  few  weeks  after  delivery  even  while 
nursing  her  baby,  though  the  quality  of  her  milk  is  likely  to  be 
unfavorably  affected  by  the  pregnancy.  But,  as  has  been  ex- 
plained, the  return  of  menstruation  does  not  necessarily  exert 
as  unfavorable  an  influence  upon  lactation  as  was  formerly  be- 
lieved. 

Abdominal  Wall.  The  abdominal  wall  is  usually  over- 
stretched during  pregnancy,  and  immediately  after  labor  when 
the  tension  is  removed,  the  skin  lies  in  folds  and  the  entire  wall 
is  soft  and  flabby.  The  normal  and  desirable  course  is  for  the 
muscles  gradually  to  regain  their  tone ;  for  the  excess  of  fat  to 
be  absorbed  and  the  walls  to  approach  their  original  state  in  the 
course  of  a  few  weeks.  The  striae  usually  remain,  and  the 
muscles  sometimes  fail  to  regain  their  tone,  as  for  example  when 
pregnancies  follow  each  other  in  rapid  succession  or  when  there 
has  been  excessive  distension.  In  such  cases  there  is  likely  to  be 
the  pendulous  abdomen  so  often  seen  in  multiparae,  and  a  dias- 
tasis, or  separation  of  the  rectus  muscles. 

Digestive  Tract.  During  the  first  day  or  two  after  delivery 
the  mother  may  have  very  little  appetite  but  she  is  usually  very 
thirsty.  She  will  almost  inevitably  be  constipated,  because  of 
the  loss  of  intra-abdominal  pressure ;  the  sluggishness  of  the  in- 
testines acquired  during  pregnancy  ;  her  recumbent  position,  lack 
of  exercise  and  the  fact  that  she  is  taking  relatively  less  food  than 
usual  and  that  her  bowels  were  freely  evacuated  at  the  onset  of 
labor. 

Temperature.  The  temperature  often  rises  to  about  99°  F. 
immediately  after  labor  but  it  should  drop  to  normal  in  a  few 
hours  and  practically  remain  so.  For  various  causes,  some  of 
which  are  unexplained,  the  temperature  will  not  infrequently 
be  slightly  above  normal  at  times  during  the  first  few  days  of 
the  puerperium,  without  the  patient's  seeming  to  suffer  any  ill 
effects.     But  the  fairly  general  agreement  among  obstetricians 


322  OBSTETRICAL  NURSING 

seems  to  be  that  a  temperature  of  100.4°  F.  is  the  upper  limit  of 
normality  and  that  infection  is  to  be  suspected  if  it  reaches 
that  point  and  remains  there  for  twenty -four  hours. 

Pulse.  The  normal  pulse  rate  is  usually  slower  during  the 
puerperium,  being  about  60  or  70  beats  to  the  minute,  and  is  re- 
ferred to  as  puerperal  bradycardia.  It  is  thought  that  this  is 
due  to  the  absolute  rest  in  bed  and  the  decreased  strain  upon 
the  heart  after  the  birth  of  the  baby. 

Skin.  There  is  usually  profuse  perspiration  during  the  first 
few  days,  while  the  elimination  of  fluids  is  most  active,  but  it 
gradually  subsides  and  becomes  normal  by  the  end  of  a  week. 
The  perspiration  sometimes  has  a  strong  odor  and  there  is  not 
infrequently  an  appreciable  amount  of  desquamation. 

Urine.  Many  patients  find  it  difficult,  even  impossible,  to 
void  urine  during  the  first  several  hours  after  delivery  because 
of  the  removal  of  intra-abdominal  pressure ;  the  recumbent  posi- 
tion and  the  swelling  and  bruised  state  of  the  tissues  about  the 
urethra.  The  bladder  is  likely  to  be  less  sensitive  than  usual 
and  the  patient  will  be  able  to  retain  an  abnormally  large  amount 
of  urine  for  several  hours  without  discomfort,  or  desire  to  void. 

The  output  of  urine  during  the  first  few  days  is  greater  than 
normal,  and  there  is  also  a  considerable  increase  in  the  amount 
of  nitrogen  excreted,  beginning  two  or  three  days  after  delivery. 
This  is  evidently  derived  from  the  broken  down  proteins  in  the 
uterine  wall,  and  the  excess  gradually  subsides  as  involution 
progresses,  and  disappears  by  the  time  the  uterus  descends  into 
the  pelvis. 

When  one  considers  the  severe  ordeal  that  the  young  mother 
has  just  passed  through,  her  recovery  and  return  to  a  normal 
state  are  surprisingly  rapid,  when  she  is  given  good  care. 


CHAPTER  XV 
NURSING  CARE  DURING  THE  NORMAL  PUERPERIUM 

In  general,  the  nursing  care  during  the  puerperium  is  much 
the  same  as  that  which  is  given  to  a  surgical  patient,  with  special 
attention  to  the  breasts  and  perineum  and  a  sustained  effort  to 
prevent  complications  and  restore  the  mother  to  a  normal  state 
of  health  in  due  time. 

As  the  nurse  doubtless  realizes  by  this  time,  the  principal 
complications  to  guard  against  during  the  puerperium  are  hemor- 
rhage from  the  still  raw  area,  Avhere  the  placenta  was  attached 
to  the  inner  surface  of  the  uterus ;  infection  of  the  birth  canal ; 
breast  abscesses;  displacement  of  the  uterus  and  subinvolution, 
or  failure  of  the  uterus  to  return  to  its  normal  size  and  condition 
in  the  usual  length  of  time. 

In  addition  to  guarding  against  these  definite  complications, 
the  nurse  must  help  to  save  her  patient  from  the  less  tangible, 
but  perhaps  equally  injurious  effects  of  fatigue  of  mind  and 
body.  As  many  young  mothers  are  in  a  more  or  less  unstable, 
excitable  condition  after  the  baby's  birth,  the  beneficial  effect 
of  promoting  a  tranquil  and  contented  state  of  mind  can  scarcely 
be  overestimated. 

The  doctor  may  be  ever  so  tactful  and  cheering  and  sustain- 
ing, but  his  contacts  with  the  patient  are  short  and  infrequent 
as  compared  with  the  nurse's  constant  companionship.  She  can, 
therefore,  by  her  attitude,  manner  and  conduct  practically  create 
or  destroy  the  atmosphere  that  is  necessarj^  to  her  patient's  wel- 
fare. 

In  order  to  give  the  best  and  most  helpful  service  the  nurse 
must  try  from  the  very  beginning  to  understand  her  patient  as 
an  individual  and  adapt  herself  to  the  patient's  temperament. 
Some  women  are  rested  and  soothed  by  being  talked  with,  read 
to,  diverted  and  amused  in  one  way  or  another,  during  most  of 

323 


324  OBSTETRICAL  NURSING 

the  time,  and  will  grow  nervous  and  depressed  if  left  to  their  own 
devices.  Others,  who  have  greater  resources  within  themselves 
are  happier  and  better  off  when  left  to  themselves  a  good  deal, 
and  given  an  opportunity  to  think  things  over.  Some  women 
are  much  subdued  as  the  consciousness  of  their  motherhood 
grows  upon  them,  and  they  feel  a  kind  of  awe  and  wonder  about 
this  baby  that  they  begin  to  realize  is  their  own.  It  is  a  big  ex- 
perience, this  one  of  motherhood,  full  of  promise  and  responsi- 
bilities, and  the  young  mother  herself  very  often  wants  to  think 
it  out.  She  will  enjoy  talking  when  she  wants  to  talk,  but  may 
be  irritated  and  exhausted  by  a  nurse  who  tries  to  entertain  her 
all  of  the  time. 

For  this  reason,  the  most  conscientious  and  painstaking  nurse 
imaginable  may  destroy  her  usefulness,  by  adopting  the  wrong 
attitude  toward  her  patient  during  this  period  of  enforced  in- 
timacy. Some  women  want,  and  even  need  to  be  indulged  and 
petted ;  but,  on  the  other  hand,  a  certain  type  of  reserved  and 
dignified  woman  is  affronted  by  such  attention  or  by  the  easy 
air  of  familiarity  that  another  courts;  one  patient  is  exhausted 
by  the  unvarying  punctuality  and  precision  of  a  conscientious, 
but  unadaptable  nurse,  while  that  very  punctuality  and  preci- 
sion is  satisfying  and  restful  to  another. 

It  is  not  a  simple  matter  to  sound  the  depths  of  a  patient's 
personality,  for  they  are  all  complex  and  each  one  is  peculiar  to 
herself.  That  fact  must  not  be  overlooked  for  each  patient  is 
an  entirely  new  and  different  problem  and  not  like  any  other 
that  the  nurse  has  had  before.  But  the  nurse  who  is  sincere  and 
sympathetic  and  who  earnestly  tries  to  put  herself  in  her  pa- 
tient's place  and  see  things  from  her  standpoint,  will,  by  virtue 
of  that  very  attitude,  accomplish  much  toward  sensing  the  pa- 
tient's temperament  and  establishing  harmonious  relations. 
Moreover,  the  patient,  herself,  will  all  unconsciously  make  some- 
thing of  an  adjustment  to  the  nurse  when  she  feels  the  nurse's 
sincerity  and  her  eagerness  to  be  of  service. 

One  factor  in  shaping  the  young  mother's  state  of  mind, 
which  the  nurse  must  take  into  account  is  that  the  entire  scheme 
and  purpose  of  her  patient's  life  have  been  changed.  She  has 
been  plunged  very  suddenly  into  a  wholly  new  condition  and 


CARE  DURING  THE  NORMAL  PUERPERIUM     325 

her  reaction  to  this  change  will  depend  upon  her  temperament, 
disposition  and  habits  of  adjustment. 

She  has  spent  nine  months  looking  forward  to  an  event  that 
has  been  consummated ;  she  has  spent  nine  months  in  a  state  of 
more  or  less  apprehension  and  suspense  that  have  been  abruptly 
ended,  and  we  know  that  it  is  quite  natural  for  any  one  to  ex- 
perience a  letting  down,  or  something  akin  to  collapse,  when 
long-continued  uncertainty  is  ended,  even  though  it  ends  hap- 
pily. 

And  as  recovery  progresses  the  patient  becomes  aware,  per- 
haps only  vaguely,  of  another  change  which  is  not  always  a  wel- 
come one.  For  nine  months  she  has  been  the  centre  of  interest 
in  her  immediate  circle ;  she  has  been  the  object  of  unremitting 
concern  and  solicitude,  and  much  as  she  and  her  family  may 
have  tried  to  keep  her  life  normal,  she  and  her  needs  have  con- 
stantly been  given  the  first  consideration.  The  very  mystery  of 
the  child  developing  within  her  has  created  an  attitude  of  re- 
spect, almost  of  reverence,  which  was  never  her  portion  before. 
In  every  way  she  has  been  shielded,  protected  and  cared  for,  and 
all  eyes,  including  her  own,  have  steadily  looked  forward  to  the 
event  for  which  this  care  has  been  preparing  her — her  ordeal 
of  childbirth  and  the  coming  of  her  baby. 

And  now  her  ordeal  is  over.  Her  baby  is  here.  Every  one 
may  be  said  to  be  breathing  easily  at  last  and  they  are  no  longer 
apprehensive  and  absorbingly  interested  in  her.  As  a  result  the 
young  mother  will  soon  become  simply  one  of  the  family  and 
the  community,  and  will  cease  to  be  the  centre  of  reverential  in- 
terest and  solicitude. 

It  is  scarcely  human  to  welcome  such  a  change  in  one 's  state, 
and  though  in  all  probability  very  few  mothers  are  conscious 
of  resenting  it,  very  many  actually  do.  And  for  this  reason  very 
many  unwittingly  cling  to  a  role  of  semi-invalidism.  It  is  en- 
tirely unconscious  on  their  part  and  it  is  also  very  human  and 
natural. 

To  aid  in  the  process  of  bracing  up  such  a  young  woman  to 
resume  her  former  life  and  to  meet  the  demands  which  it  im- 
poses :  or  to  protect  another  patient  of  the  eager,  buoyant  type 
from   exposing  herself  too   early   to  the   onslaughts  made  by 


326  OBSTETRICAL  NURSING 

everyday  life,  is  far  from  beiug  a  simple  task,  and  to  meet  it  no 
one  rule  can  be  laid  down.  There  are  all  of  the  variations  and 
degrees  between  the  timid  or  self-indulgent  woman,  who  must 
be  encouraged  and  spurred  on,  and  the  too  active,  ambitious  pa- 
tient, who  must  be  steadied  and  held  back  for  a  time. 

But  here,  again,  this  is  simply  a  part  of  the  nurse's  duty; 
one  aspect  which  makes  nursing  the  gratifying  service  that  it  is». 

Fortunately  the  majority  of  young  mothers  are  happy  and 
normal  in  their  outlook  and  may  be  kept  so  by  the  exercise  of 
an  average  amount  of  tact  and  amiability  on  the  part  of  the 
nurse.  The  actual  physical  care  of  the  patient  during  the  puer- 
perium  is  a  fairly  simple  matter  for  the  well  trained  nurse.  She 
will  find,  however,  that  in  hospitals,  private  practice  and  pub- 
lic-health work  alike  there  will  be  wide  differences  in  the  treat- 
ment given  by  different  doctors,  during  this  period,  just  as 
there  were  during  pregnancy  and  labor,  and  she  will  have  to 
carry  out  the  prescribed  directions  enthusiastically  and  loyally 
no  matter  how  they  vary  from  those  of  the  doctors  who  helped 
in  her  training. 

The  details  of  the  care  will  be  indicated  by  the  individual 
doctor,  but  the  general,  underljdng  principles — cleanliness, 
watchfulness,  adaptability  and  sympathetic  understanding  will 
apply  to  the  nursing  of  all  patients.  The  most  notable  differ- 
ences of  opinion  relate  to  the  care  of  the  breasts,  the  perineum 
and  the  use  of  abdominal  binders,  the  accepted  routine  for  the 
general  nursing  of  average,  normal  cases  being  fairly  uniform 
the  country  over. 

NURSING  CARE 

As  has  been  stated,  the  general  nursing  care  of  the  puerperal 
patient  is  much  the  same  as  that  given  to  any  surgical  patient, 
with  such  adaptations  as  are  indicated  by  the  condition  and 
needs  of  the  young  mother. 

Position  in  Bed.  The  question  of  the  patient's  position  In 
bed  is  probably  the  first  one  that  presents  itself  to  the  nurse 
after  that  first  hour  when  the  patient  must  be  kept  flat  on  her 
back  and  the  fundus  closely  watched.  She  should  continue  to 
lie  quietly  on  her  back  for  a  few  hours,  with  only  a  small  pillow 


CARE  DURING  THE  NORMAL  PUERPERIUM     327 

under  her  head,  as  moving  about  may  cause  hemorrhage.  Some 
doctors  permit  the  patient  to  turn  from  side  to  side  at  will  after 
a  few  hours  of  quiet,  while  others  do  not  allow  this  for  two 
or  three  days  particularly  if  the  patient  has  perineal  stitches, 
unless  her  knees  are  tightly  bound  together.  Their  reason  for 
this  precaution  is  fear  that  the  stitches  may  be  torn  out  if  the 
thighs  are  separated  and  also  that  air  may  gain  access  to  the 


Fig.  116. — Height  of  fundus  on  each  of  tlie  first  ten  days  after  delivery. 

uterine  vessels,  through  the  relaxed  and  gaping  birth  canal,  and 
produce  air  embolism.  It  is  a  routine  in  some  hospitals  to  keep 
the  head  of  the  patient's  bed  elevated  during  the  first  week,  to 
promote  drainage,  but  as  a  rule  it  is  in  the  usual  position. 

Quite  commonly  the  patient  is  encouraged  to  lie  first  on  one 
side  and  then  on  the  other,  after  she  begins  to  move  about  in 
bed  unassisted,  and  then  face  downward  ut  intervals,  in  order 
to  change  the  position  of  the  uterus  and  thus  tend  to  prevent 
backward  displacement 


328  OBSTETRICAL  NURSING 

In  many  hospitals,  it  is  part  of  the  daily  routine  to  measure 
and  record  the  height  of  the  fundus  (Fig.  116)  above  the  sym- 
physis, in  addition  to  noting  the  character,  amount  and  odor  of 
the  lochia,  in  order  to  judge  if  involution  is  progressing  nor- 
mally. A  uterus  that  does  not  remain  firm  and  does  not  steadily 
shrink  in  size  and  descend  into  the  pelvis  is  not  involuting  prop- 
erlj^,  and  the  usual  remedy  is  more  rest  and  a  longer  stay  in 
bed,  with  an  icecap  over  the  fundus. 

Sitting  Up.  Except  when  there  are  perineal  stitches  or  the 
temperature  has  been  elevated  at  some  time  following  delivery, 
the  patient  is  ordinarily  allowed  to  sit  up  in  bed  about  the  sixth 
or  eighth  day.  If  the  lochia  is  normal,  the  uterus  firm  and  in  the 
proper  position  in  the  abdomen  and  her  general  condition  sat- 
isfactory, she  is  allowed  to  sit  up  in  a  chair  for  a  little  while 
about  the  ninth  or  tenth  day.  Some  patients  are  able  to  sit  up 
for  an  hour  the  first  time  without  being  tired,  but  it  is  often 
better  for  them  to  sit  up  for  a  few  moments  morning  and  after- 
noon on  the  first  day,  than  for  a  longer  time  at  one  stretch.  The 
patient  is  usually  allowed  to  sit  up  an  hour  longer  on  each  suc- 
cessive day  and  to  walk  a  few  steps  on  the  third  or  fourth  day 
after  getting  up. 

A  patient  with  stitches  does  not  usually  sit  up  in  bed  until 
the  ninth  or  tenth  day,  when  the  stitches  are  removed,  sitting  up 
in  a  chair  for  an  hour,  two  or  three  days  later.  If  she  has  had 
fever,  the  time  at  which  she  may  sit  up  will  of  necessity  depend 
upon  her  condition. 

The  return  to  normal  life  must  be  very  gradual  and  this  also 
must  be  regulated  by  the  patient's  general  condition  and  her  re- 
cuperative powers.  A  pinkish  or  red  discharge  or  backache 
should  be  taken  as  warnings  against  standing  or  walking  or 
working.  The  possible  consequences  of  ignoring  these  warnings 
and  being  up  and  about  too  soon,  may  be  displacement,  even  pro- 
lapse of  the  uterus;  hemorrhage,  from  dislodgment  of  clots  in 
the  uterine  vessels;  metritis  or  endometritis. 

It  is  not  a  good  plan,  as  a  rule,  for  the  patient  to  go  up  and 
down  stairs  until  the  baby  is  about  four  weeks  old,  nor  wholly 
to  resume  her  normal  activities  within  six  or  eight  weeks  after 
delivery. 


CARE  DURING  THE  NORMAL  PUERPERIUM     329 

In  addition  to  this  sustained,  general  care,  it  is  a  customary 
preventive  measure  for  the  doctor  to  make  a  thorough  pelvic  ex- 
amination from  four  to  six  weeks  after  delivery.  A  slight  ab- 
normality, if  detected  at  this  time  may  usually  be  corrected  with 
little  difficulty,  but  if  allowed  to  persist  may  result  in  chronic 
invalidism  or  necessitate  an  operation.  If  the  uterus  is  not  prop- 
erly involuted,  for  example,  or  the  perineum  is  found  to  be 
flabby,  more  rest  in  bed  is  indicated;  while  a  uterine  displace- 
ment, which  seems  to  be  present  in  about  a  third  of  all  cases, 
usually  may  be  corrected  by  the  adjustment  of  a  pessary. 

The  time  of  sitting  up,  of  getting  up  and  of  walking  about 
varies  so  with  the  individual,  therefore,  that  it  is  not  possible  to 
describe  a  definite  routine,  for  some  patients  recover  slowly  and 
would  be  injured  by  getting  up  and  about  at  a  period  which 
would  be  entirely  safe  and  normal  for  the  majority.  It  must  be 
determined  in  each  case  by  the  condition  of  the  uterus,  the  ap- 
pearance and  amount  of  the  lochia  and  the  patient 's  general  con- 
dition. 

Quite  evidently,  then,  much  ill  health  and  many  gyneco- 
logical operations  may  be  prevented  by  caution,  prudence  and 
good  care  during  the  first  few  days  and  weeks  after  the  baby's 
birth,  while  the  patient  returns  to  a  normal  mode  of  living. 

The  Daily  Bath.  During  the  first  week  or  two  the  patient's 
skin  must  aid  in  excreting  fluids  from  the  edematous  tissues 
throughout  the  body  and  broken  down  products  from  the  invo- 
luting uterus.  Therefore  she  should  have  a  bath  of  warm  water 
and  soap  every  day,  to  remove  material  already  on  the  surface 
and  stimulate  the  skin  to  further  activity,  and  an  alcohol  rub  at 
night,  if  possible.  It  is  important  for  the  nurse  to  remember, 
while  bathing  her  patient,  that  she  is  perspiring  freely  and  there- 
fore may  be  easily  chilled  if  not  well  protected. 

It  is  often  a  good  plan  to  have  the  patient,  without  stitches, 
begin  to  bathe  herself  in  bed,  after  the  third  or  fourth  day,  for 
the  sake  of  the  exercise,  and  also  the  encouragement  that  it  of- 
fers. When  all  is  going  well,  tub-bathing  is  usually  resumed  by 
the  third  or  fourth  week. 

Diet.  Opinions  as  to  diet  vary  slightly  with  different  doctors 
and  in  different  hospitals,  but  in  general,  a  patient  in  good 


330     •  OBSTETRICAL  NURSING 

condition  is  given  liquid  food  during  the  first  twelve  to  twenty- 
four  hours  after  delivery;  then  a  soft  diet  for  a  day  or  two,  a 
nourishing,  light  diet  being  resumed  by  the  third  or  fourth  day. 
or  after  the  bowels  have  moved  freely. 

The  patient  will  usually  have  little  appetite,  at  first,  and  will 
have  to  be  tempted  by  small  amounts  of  invitingly  served  food. 
The  factors  which  the  nurse  must  bear  in  mind  when  arranging 
the  patient 's  dietary  are  the  general  nutrition  of  the  mother ;  the 
desirability  of  minimizing  her  loss  of  weight  during  the  puer- 
perium;  increasing  her  strength  and,  particularly,  of  promoting 
the  function  of  her  breasts,  in  order  to  produce  milk  of  a  quality 
and  quantity  adequate  to  nourish  the  baby. 

The  best  producer  of  such  milk  is  a  diet  consisting  largely 
of  milk,  eggs,  leafy  vegetables  and  fresh  fruits,  taken  with  an 
appetite  that  is  made  keen  by  constant  fresh  air.  The  nurse 
will  do  well  to  convince  her  patient  of  this,  in  addition  to  bearing 
it  in  mind  herself,  and  to  place  little  reliance  on  so-called  milk 
producing  foods. 

The  young  mother's  dietary  may  well  be  made  up  from  the 
groups  of  foods  that  are  suitable  for  the  expectant  mother.  (See 
Chapter  VI).  At  this  time,  as  during  pregnancy,  she  must 
avoid  all  food  which  may  produce  any  form  of  indigestion,  but 
for  the  baby's  sake,  now,  as  well  as  her  own.  While  it  is  not 
generally  believed,  to-day,  that  there  are  many,  if  any  articles 
of  diet  which  in  themselves  affect  the  mother 's  milk  unfavorably, 
it  is  generally  conceded  that  a  derangement  of  her  digestion  may, 
and  usually  does,  have  a  deleterious  effect  upon  her  milk,  and 
therefore  upon  the  baby. 

The  old,  and  widespread,  belief  that  certain  substances  from 
such  highly  flavored  vegetables  as  onions,  cabbage,  turnips  and 
garlic  are  excreted  through  the  milk,  to  the  baby's  detriment,  is 
not  given  general  credence  to-day.  On  the  other  hand,  it  is 
known,  however,  that  certain  protective  substances  in  certain 
foods  are  excreted  through  the  milk,  to  the  baby's  distinct  ad- 
vantage, and  it  is  therefore,  important  that  the  mother's  diet 
should  regularly  contain  those  articles  of  food  which  contain 
them.  These  foods  are  milk;  egg  yolk;  glandular  organs,  such 
as  sweet-breads,  kidneys  and  liver;  the  green  salads,  such  as 


CARE  DURING  THE  NORMAL  PUERPERIUM      331 

lettuce,  romaine,  endive  and  cress  and  the  citrous  fruits,  or 
oranges,  grapefruit  and  lemons. 

These  are  called  "protective  foods"  because  they  protect  the 
body  against  the  so-called  deficiency  diseases  known  as  scurvy, 
beri-beri,  xerophthalmia,  \vhi(;h  with  rickets  and  pellagra  are 
discussed  in  the  chapter  on  Nutrition.  It  is  possible  for  a  baby 
who  nurses  at  the  breast  of  a  woman  whose  diet  is  poor  in  pro- 
tective foods,  to  be  so  insufficiently  nourished,  in  some  particu- 
lar, as  to  be  on  the  border  line  of  one  of  these  diseases,  or  even 
to  develop  the  disease  itself.  This  is  one  reason  for  the  state- 
ment that  the  nursing  mother  must  "eat  for  two." 

Certain  drugs  are  excreted  through  the  milk  and  may  affect 
the  baby  in  the  same  way  as  though  they  were  administered  di- 
rectly, for  example :  salicylic  acid,  potassium  iodid,  lead,  mer- 
cury, iron,  arsenic,  atropin,  chloral,  alcohol  and  opium.^ 

In  addition  to  her  food  the  nursing  mother  should  have  an 
abundance  of  water  to  drink,  and  to  facilitate  this  it  is  a  good 
plan  to  keep  a  pitcher  or  thermos  bottle  of  water  on  the  bedside 
table,  and  replenish  it  regularly,  every  four  hours. 

In  general,  the  young  mother  should  have  light,  nourishing, 
easily  digestible  food,  with  little,  if  any  meat;  an  abundance  of 
cereals,  creamed  dishes,  creamed  soups,  eggs,  salads  and  the  fresh 
fruits  and  vegetables  which  ordinarily  agree  with  her ;  at  least  a 
quart  of  milk,  daily,  in  addition  to  that  which  is  used  in  prepar- 
ing her  meals,  and  an  abundance  of  water  to  drink. 

The  Bowels.  The  puerperal  patient  is  almost  always  con- 
stipated, and  needs  assistance  in  regaining  regularity  in  the 
movements  of  her  bowels. 

The  routine  use  of  cathartics  and  enemata  varies,  but  it  is 
very  common  to  give  an  enema  on  the  second  morning  after 
delivery  or  castor  oil  or  Rochelle  salts,  followed  by  an  enema  if 
necessary.  After  this,  a  mild  cathartic  or  a  low  enema  is  given 
often  enough  to  produce  a  daily  movement  when  this  is  not 
accomplished  by  means  of  the  diet. 

Some  doctors,  however,  prefer  that  the  bowels  shall  not  move 
for  four  or  five  days  after  delivery,  believing  that  this  delay  re- 

»"The  Practice  of  Obstetrics,"  by  J.  Clifton  Edgar. 


332  OBSTETRICAL  NURSING 

duces  the  danger  of  infection  from  the  intestinal  contents,  which 
are  swarming  with  organisms,  particularly  the  colon  bacillus. 

In  cases  of  third  degi'ee  tears,  catharsis  is  practically  always 
delayed  for  four  to  six  days  in  order  that  the  torn  edges  of  the 
rectal  sphincter  may  become  well  united  before  being  strained 
by  a  bowel  movement.  In  these  cases  an  enema  of  six  or  eight 
ounces  of  warm  olive  oil  is  often  given  and  the  patient  encour- 
aged to  retain  it  over  night,  in  order  to  soften  the  contents  of 
the  rectum  and  lessen  the  strain  and  irritation  of  evacuation. 

The  Bladder.  The  question  of  helping  the  patient  to  void 
after  delivery  is  one  of  extreme  importance,  because  she  will  al- 
most certainly  have  difficulty  in  emptying  her  bladder,  and  yet 
catheterization  is  not  to  be  resorted  to  unless  absolutely  neces- 
sary. As  a  rule  the  patient  should  be  encouraged  to  try  to  void 
from  four  to  eight  hours  after  delivery.  If  she  is  unable  to  do 
so  at  first  there  are  several  aids  which  the  nurse  should  employ 
before  admitting  the  patient's  inability  to  empty  her  bladder. 
Inducing  her  to  drink  copious  amounts  of  hot  fluids  is  the  first 
step.  Very  often  she  will  then  void  if  placed  upon  a  bedpan 
containing  water  hot  enough  to  give  off  steam,  and  more  warm, 
sterile  water  is  poured  directly  upon  the  urethral  outlet ;  or  hot 
and  cold  sterile  water  may  be  dashed,  alternately,  upon  the 
meatus. 

The  sound  of  running  water  is  often  helpful  as  well  as  the  ap- 
plication of  hot  stupes  over  the  supra-pubic  region.  When  every- 
thing else  fails,  success  frequently  follows  the  application  of  a 
partly  filled  hot-water  bottle  over  the  bladder,  held  in  place  by 
a  tight  binder,  particularly  if  the  patient"  rests  upon  a  pan  of 
steaming  water  at  the  same  time. 

The  danger  of  infecting  the  bladder,  by  carrying  lochia  into 
it  upon  the  catheter,  is  so  great  that  some  doctors  choose  what 
they  regard  as  the  lesser  of  two  evils,  and  allow  the  patient  to 
be  assisted  to  the  sitting  position,  if  she  has  not  a  serious  tear. 
Not  infrequently  the  patient's  inability  to  void  is  due  to  the 
fact  that  she  is  unaccustomed  to  using  a  bedpan,  and  would  have 
difficulty  in  using  one  under  any  conditions,  but  is  able  to  void 
while  sitting  up.  As  the  danger  of  infection  is  greater  two  or 
three  days  after  delivery  than  at  first,  because  of  the  beginning 


CARE  DURING  THE  NORMAL  PUERPERIUM      333 

decomposition  of  the  lochia,  it  is  very  evidently  important  to 
help  the  patient  to  establish  the  habit  of  voiding  from  the  be- 
ginning, for  if  she  is  catheterized  once  there  is  great  likelihood 
that  she  will  need  to  have  it  continued  for  some  days. 

If  the  first  attempts  are  unsuccessful,  therefore,  but  the  pa- 
tient thinks  that  slie  may  be  able  to  void  later,  if  the  efforts  are 
repeated,  catheterization  is  sometimes  delayed  for  as  long  as 
sixteen  to  eighteen  hours  after  delivery  in  the  hope  that  it  may 
be  avoided  altogether. 

When  the  most  persistent  and  painstaking  efforts  fail,  and 
catheterization  is  necessary,  the  nurse  must  remember  the  ex- 
treme gravity  of  her  responsibility  and  preserve  asepsis  through- 
out the  procedure.  Although  there  is  extreme  danger  of  infec- 
tion, it  can  be  prevented  as  a  rule,  and  its  occurrence  is  there- 
fore regarded  as  almost  inexcusable. 

In  preparing  for  catheterization,  the  nurse  should  drape  the 
patient  as  for  a  vaginal  examination,  making  sure  that  she  is 
warmly  covered,  and  place  her  on  a  sterile  douche-  or  bedpan. 
If  it  is  done  at  night  she  should  place  the  light  in  a  position  at 
once  safe  and  advantageous.  She  should  have  at  hand  on  a 
tray:  sterile  forceps;  cotton  pledgets;  two  glass  catheters  (in 
case  one  should  be  broken  or  become  contaminated)  ;  a  disinfect- 
ing solution  such  as  bichlorid,  1-4,000  or  lysol  1  per  cent. ;  a 
sterile  receptacle  in  which  to  receive  the  urine ;  sterile  towels 
and  a  dressing  basin  or  paper  bag  for  the  used  pledgets. 

The  preparation  of  the  nurse's  hands,  at  this  point,  varies 
in  different  hospitals,  but  always  the  greatest  care  is  taken  to 
bring  nothing  unsterile  in  contact  with  the  vulva  and  meatus. 

According  to  one  method,  the  nurse  scrubs  her  hands  for 
three  minutes  and  prepares  the  patient  as  for  a  vaginal  exam- 
ination, removes  the  douche  pan  and  places  a  sterile  towel  over 
the  vulva.  She  then  scrubs  and  soaks  her  hands  as  described  in 
Chapter  XII,  puts  on  sterile  gloves,  places  a  sterile  towel  over 
the  patient's  abdomen  and  slips  one  under  her  hips.  She  should 
then  separate  the  labia  with  the  gloved  fingers  of  the  left  hand, 
drawing  the  fingers  upward  a  little  to  make  the  meatus  more 
prominent.  The  inner  surface  of  the  labia  is  then  bathed  with 
pledgets  soaked  with  the  disinfecting  solution,  with  downward 


334  OBSTETRICAL  NURSING 

strokes,  each  pledget  being  used  but  once.  Five  or  six  pledgets 
should  be  used,  one  after  the  other,  to  sponge  the  meatus,  each 
pledget  being  placed  squarely  against  the  orifice,  without  touch- 
ing the  adjacent  tissues,  and  given  a  slight,  downward  twisting 
motion  and  discarded.  The  bowl  may  then  be  placed  in  position 
to  receive  the  urine,  and  the  catheter  picked  up  with  the  fingers, 
by  its  open  end.  The  rounded  end  must  be  carefully  inspected 
to  insure  against  using  one  that  is  cracked  or  broken,  after  which 
it  is  slowly  and  gently  introduced  into  the  urethra  for  two  or 
three  inches.  If  the  urine  does  not  flow  freely  the  catheter  may 
be  slightly  withdrawn  and  light  pressure  made  upon  the  bladder. 

Before  removing  the  catheter  the  nurse  must  locate  the  fun- 
dus and  assure  herself  that  it  is  in  a  proper  position.  If  it  is 
pushed  up  or  to  one  side  she  will  know  that  the  bladder  is  still 
distended,  and  that  more  urine  must  be  withdrawn.  After  the 
bladder  has  been  emptied  the  nurse  should  place  one  finger  over 
the  open  end  of  the  catheter  and  remove  it  slowly. 

Another  method  of  catheterization  differs  from  the  one  just 
described,  in  the  preparation  of  the  nurse's  hands.  In  this  in- 
stance she  simply  washes  her  hands  well  with  soap  and  hot 
water  and  wears  neither  gloves  nor  finger  cots. 

She  bathes  the  vulva  with  pledgets  and  an  antiseptic  solu- 
tion, using  forceps,  and  then  separates  the  labia  with  two  dry 
pledgets,  one  each  under  forefinger  and  thumb  of  the  left  hand, 
and  proceeds  as  above.  It  will  be  observed  that  the  nurse  avoids 
touching  the  inner  surface  of  the  labia  or  the  meatus  with  any- 
thing but  sterile  pledgets  and  the  sterile  catheter.  The  advan- 
tage of  this  procedure  is  that  it  is  accomplished  quickly  and  with 
the  minimum  of  disturbance  to  the  patient. 

A  distended  bladder  may  so  easily  occur  unless  the  patient 
is  carefully  observed  during  the  puerperium  that  the  nurse 
should  charge  herself  to  watch  for  this  complication.  She  should 
give  the  patient  a  bedpan  every  four  hours,  note  the  contour  of 
the  abdomen  and  measure  the  urine  during  the  first  week,  re- 
membering that  the  patient  should  void  considerably  more  than 
the  average  amount,  both  because  of  the  amount  of  milk  and 
water  that  she  is  taking,  and  the  fluid  which  she  is  eliminating 
from  her  tissues.     The  importance  of  measuring  the  urine  lies 


CARE  DURING  THE  NORMAL  PUERPERIUM      335 

in  the  fact  that  though  the  patient  may  void  fairly  regularly  she 
may  not  empty  her  bladder,  and  thus  enough  urine  may  accumu- 
late to  distend  it. 

The  temperature,  pulse  and  respirations  are  usually  taken 
and  recorded  every  four  hours  for  the  first  five  or  six  days  and 
then  two  or  three  times  daily,  if  normal.  If  the  temperature  is 
above  normal  at  any  time,  the  nurse  should  take  it  every  two 
hours  until  it  becomes  normal  and  notify  the  doctor  immediately 
if  it  goes  as  high  as  100.4°  F.,  or  if  the  pulse  reaches  100. 

Care  of  the  Perineum.  The  best  way  of  caring  for  the  peri- 
neum, during  the  first  week  or  ten  days  after  delivery,  is  a  moot 
question,  and  the  nurse  may  find  herself  sorely  perplexed  by  the 
widely  divergent  instructions  of  different  doctors  who  have 
excellent  results,  unless  she  goes  back  of  the  details  themselves 
and  recognizes  their  purpose.  She  will  then  see  that  there  is 
entire  agreement  about  the  importance  of  protecting  the  patient 
against  infection,  at  this  time,  when  infection  may  so  easily 
occur.  And  so  far  as  the  nurse  is  concerned,  this  means  clean- 
liness as  to  methods  and  appliances,  when  making  perineal 
dressings,  and  extreme  precaution  against  conveying  infection 
to  her  patient.  The  minimum  requisites  for  this  are  that  the  bed- 
pan shall  be  sterilized,  by  steam  or  boiling,  at  least  once  a  day, 
and  well  scrubbed  and  scalded  after  each  time  that  it  is  used,  and 
that  the  nurse  shall  at  least  scrub  her  hands  with  soap  and  hot 
water  before  making  each  perineal  dressing,  and  apply  only  ster- 
ile pads. 

After  the  perineum  is  bathed,  immediately  following  deliv- 
ery, the  usual  practice  is  to  apply  a  sterile  pad,  after  which  a 
fresh  one  is  applied  as  often  as  necessary  at  first,  every  four 
hours  during  the  first  week  and  subsequently  every  eight  hours. 
When  the  dressing  is  changed,  and  after  each  voiding  and  defeca- 
tion, the  perineum  is  bathed  with  sterile  pledgets  and  some  such 
antiseptic  solution  as  bichlorid  1-2,000  or  lysol  i/o  per  cent,  or 
1  per  cent.  (Figs.  117  and  118.)  The  soiled  pad  must  always 
be  removed  from  above  downward  and  the  bathing  also  directed 
toward  the  rectum,  each  pledget  being  used  for  one  stroke  only. 
The  rectum  is  bathed  last,  a  fresh  sterile  pad  applied  and  the 
patient's  hips  and  back  thoroughly  dried. 


836 


OBSTETRICAL  NURSING 


The  nurse  may  be  required  to  scrub  and  soak  her  hands, 
wear  sterile  gloves  and  hold  the  pledgets  in  forceps  when  bathing 
the  perineum,  the  object  of  such  precautions  being,  quite  clearly, 
to  avoid  infecting  the  patient  from  without,  for  the  inner  surface 
of  the  uterus  is  still  regarded  as  an  open  wound. 


PiQ.  117.— Preparation  and  draping  of  patient  for  post-partum  dress- 
ing Note  rack  of  equipment  on  table;  bag  of  dry,  sterile  pledgets  at 
head  of  bed;  paper  bag  on  floor  for  used  pledgets.  The  nurse  has 
scrubbed  her  hands.  (From  photograph  taken  at  The  Manhattan  Maternity 
Hospital.) 

Some  obstetricians  believe  that  the  perineal  pad  is  a  menace, 
since  it  slips  and  moves  about,  and  thus  may  transfer  infective 
material  from  the  anus  to  the  vagina.    Accordingly,  they  forbid 


CARE  DURING  THE  NORMAL  PUERPERIUM      337 

the  use  of  all  perineal  dressings  and  instead  have  large,  sterile, 
absorbent  pads  slipped  under  the  patient's  hips  to  receive  the 
lochia,  the  pads  being  changed  as  often  as  necessary.  This  is 
the  practice  at  the  Brooklyn  Hospital,  for  example,  where  the 
nurse  bathes  the  vulva  with  lysol  1  per  cent,  placing  the  patient 
on  a  sterile  bedpan,  using  sterile  forceps  and  cotton  swabs  and 
wearing  sterile  gloves  while  making  the  dressing. 

Another  method  is  to  place  the  patient  on  a  sterile  bedpan, 
remove  the  pad  and  wdth  gloved  hands  pour  from  a  sterile  pitcher 
a  warm  antiseptic  solution  over  the  groin  and  outside  of  the 


Tig.  118. — Equipment,  in  rack,  used  at  The  Manhattan  Maternity 
Hospital  in  bathing  perineum.  A,  pitcher  of  lysol,  1%.  B,  basin  of  pled- 
gets in  lysol.     C,  sponge-sticks  in  alcohol. 


vulva ;  then  to  separate  the  labia  and  pour  the  solution  between 
them,  in  some  instances  pressing  a  dry,  sterile  pledget  to  the 
vaginal  orifice  during  the  irrigation. 

When  the  urine  is  being  measured,  as  it  frequently  is  during 
the  first  week,  the  solution  which  is  used  for  irrigating  the  vulva 
should  be  measured  beforehand  and  the  contents  of  the  bedpan 
measured  after  the  dressing,  in  order  that  the  amount  of  urine 
passed,  if  any,  may  be  ascertained. 

Another  method  of  bathing  the  perineum,  that  employed  at 
Johns  Hopkins  Hospital,  is  simply  to  bathe  the  perineum  with 


338  OBSTETRICAL  NURSING 

soap  and  warm  water,  without  separating  the  labia,  using  a  clean 
wash  cloth  and  afterwards  applying  a  sterile  pad,  the  pads  being 
changed  every  four  hours,  or  oftener  if  necessary.  The  theory 
upon  which  this  procedure  is  based  is  that  the  steady  outward 
flow  of  the  lochia  constantly  carries  material,  infective  and 
otherwise,  away  from  the  generative  tract,  and  that  if  nothing 
is  introduced  between  the  labia  or  into  the  vagina  the  patient 
will  not  be  infected. 

In  caring  for  the  perineum,  the  nurse  must  remember  also 
the  real  danger  of  the  patient  infecting  herself  with  her  own 
fingers  and  should  caution  her  against  taking  this  risk.  The 
patient  should  be  told  that  if  she  feels  uncomfortable,  or  thinks 
she  is  bleeding,  she  must  lie  quietly  and  summon  a  nurse,  but  on 
no  account  to  try  to  find  out  for  herself  what  is  wrong.  There 
is  little  doubt  that  cases  of  severe  infection  have  been  caused 
by  the  introduction  of  organisms  into  the  vagina  by  means  of 
the  patient's  own  fingers,  after  the  most  scrupulous  precautions 
had  been  taken  by  doctors  and  nurses  to  avoid  that  very  disaster. 

In  most  instances  the  care  of  the  perineum  is  the  same 
whether  or  not  there  are  stitches,  and  in  any  case  the  method  em- 
ployed will  be  specified  by  the  doctor.  The  nurse 's  responsibility 
is  to  appreciate  the  object  of  the  care,  whatever  form  it  may 
take,  and  bring  intelligence  to  bear  in  giving  it. 

When  there  are  perineal  stitches,  it  is  a  wise  and  harmless 
precaution  to  fasten  a  towel  or  bandage  about  the  patient 's  knees 
for  a  few  days,  to  prevent  her  pulling  apart  the  uniting  edges 
of  the  tear  as  she  moves  about  in  bed. 

Douches.  In  connection  with  perineal  dressings,  it  may  be 
well  to  caution  the  nurse  against  giving  douches  without  explicit 
orders.  Douches  are  seldom  given  early  in  the  puerperium,  for 
fear  of  carrying  infective  material  up  into  the  uterus,  except 
occasionally  in  cases  of  hemorrhage,  in  which  case  they  are  given 
by  the  doctor. 

Sometimes,  however,  a  low  vaginal  douche  is  given  daily  for 
some  time  after  the  patient  gets  up,  with  the  idea  of  increasing 
her  comfort  and  promoting  involution.  About  two  quarts  of 
some  weak  antiseptic  solution  at  110°  F.  is  given  with  the  nozzle 
introduced  just  within  the  vaginal  outlet,  and  the  container  of 


CARE  DURING  THE  NORMAL  PUERPERTT^M     339 

the  solution  placed  only  slightly  above  the  level  of  the  patient's 
hips,  in  order  that  the  stream  may  be  very  gentle. 

The  Care  of  the  Breasts.     There  is  a  wide  difFerenee  of 
opinion  about  the  proper  care  of  the  breasts,  also,  but  here  again, 


Fig.  119. — Sterile  g:auze  held  in  place  over  nipples  by  means  of  adhesive 
strips  and  tapes.      (From  photograph  taken  at  Bellevue  Hospital.) 

although  the  details  vary,  the  ultimate  objects  of  the  care  are 
always  the  same,  namely:  to  facilitate  the  baby's  nursing,  pro- 
mote the  mother's  comfort  and  prevent  breast  abscesses.    These 


340  OBSTETRICAL  NURSING 

ends  are  usually  accomplished  by  keeping  the  nipples  clean  and 
intact  and  by  giving  support  and  rest  to  heavy,  painful  breasts. 

The  patient  who  has  cared  for  her  nipples  during  the  latter 
part  of  pregnancy  will  usually  have  little  or  no  trouble  with 
them  during  the  period  of  lactation,  if  the  care  is  continued. 
But  this  attention  is  imperative. 

It  is  very  generally  customary  to  have  the  nipples  bathed  be- 
fore and  after  each  nursing  with  a  saturated  solution  of  boracic 
acid,  in  either  water  or  alcohol,  using  sterile  pledgets  and  for- 
ceps, and  to  keep  them  clean  between  nursings  by  applying  ster- 
ile gauze.  This  gauze  may  be  held  in  place  by  means  of  a  breast 
binder  or  by  tapes  tied  through  the  ends  of  narrow  strips  of 
adhesive  plaster,  four  being  applied  to  each  breast.  (Fig. 
119.)  Strips  of  adhesive  plaster  about  five  inches  long  are  folded 
over  at  one  end,  two  adhesive  surfaces  being  in  contact  for  about 
an  inch.  Through  a  hole  in  the  folded  end  a  narrow  tape  or 
bobbin  is  tied  and  the  strips  applied  to  the  breast,  beginning  at 
the  margin  of  the  areola  and  extending  outward.  The  free  ends 
of  the  tapes  are  tied  over  squares  of  sterile  gauze,  between  nurs- 
ings, and  untied  to  expose  the  nipple  at  nursing  time. 

Lead  shields  are  sometimes  used  to  protect  the  healthy  nipple 
and  not  infrequently  are  applied  to  cracked  nipples,  being  held 
in  pface  by  means  of  a  breast  binder.  The  secretion  of  milk 
which  escapes  into  the  shield  is  acted  upon  by  the  metal  and  the 
result  is  a  lead  wash  which  continuously  bathes  the  nipple.  The 
shields  should  be  scrubbed  with  sapolio  and  boiled  once  daily. 

Another  method,  and  one  widely  employed,  is  to  anoint  the 
nipple  after  nursing  with  sterile  albolene  or  a  paste  of  sterile 
bismuth  and  castor  oil,  and  apply  squares  of  sterile  paraffin 
paper.  These  bits  of  paper  are  pressed  into  place  and  held  for 
a  moment  by  the  nurse 's  hand,  the  warmth  of  which  softens  and 
moulds  them  to  the  breast  after  which  they  remain  in  place. 
In  some  instances  the  bismuth  and  castor  oil  paste  is  wiped  off, 
with  a  sterile  pledget,  before  nursing  and  in  others  it  is  not. 

In  some  hospitals,  neither  gauze  nor  paper  is  used,  the  nip- 
ples being  protected  by  putting  sterile  night-gowns  on  the  pa- 
tients. 

The  purpose  of  all  of  these  methods  is  to  keep  the  nipples 


CARE  DURING  THE  NORMAL  PUERFERIUM      341 

clean,  and  here  again  the  patient  must  be  cautioned  against  in- 
fecting herself.  No  amount  of  care  on  the  nurse's  part  will 
protect  the  patient  if  she  touches  her  nipples  with  her  jSngers. 

The  nurse  will  appreciate  the  reason  for  all  of  this  pains- 
taking care  if  she  calls  to  mind  the  fact  that  the  breast  tissues 
are  highly  vascular  and  excessively  active  at  this  time  and 
therefore  very  susceptible  to  infection,  and  also  that  the  baby's 
suckling  is  often  very  vigorous  and  accompanied  by  a  good  deal 
of  chewing  and  gnawing  of  the  nipples.    Unless  the  nipples  have 


Fig.  120. — Protecting  cracked  nipples  by  having  the  baby  nurse  through 
a  shield.     (From  photograph  taken  at  Johns  Hopkins  Hospital.) 

been  toughened,  and  sometimes  even  when  they  have,  the  skin 
becomes  abraded  or  cracked  as  a  result  of  the  baby's  suckling, 
thus  creating  a  portal  of  entry  for  infecting  organisms,  in  addi- 
tion to  the  milk  ducts  which  lead  back  into  the  breast  tissues. 
Unless  the  nipples  are  kept  clean,  constantly,  they  may  become 
infected  by  organisms  from  the  baby's  mouth  or  on  the  patient's 
hands,  bedding  or  gown  with  a  breast  abscess  as  a  result.  The 
important  thing,  then,  is  to  keep  the  nipples  clean  and  not  allow 
anything  unsterile,  excepting  the  baby's  mouth,  to  come  in  con- 
tact with  them  at  any  time. 

It  is  sometimes  the  practice  to  swab  the  baby's  mouth  with 


342  OBSTETRICAL  NURSING 

boric  soaked  cotton  or  gauze  before  each  nursing,  but  many 
doctors  hold  that  this  is  injurious  to  the  delicate  mucous  lining 
of  the  baby's  mouth.  The  opinions  for  and  against  this  routine 
seem  to  be  about  equally  prevalent. 

If  the  nipples  become  painful  or  cracked,  one  can  easily 
understand  that  continued  suckling  would  only  aggravate  the 
condition  and  increase  the  danger  of  infection.  But  the  baby 
must  nurse,  if  possible,  and  so  in  the  majority  of  cases  a  nipple 
shield  is  used  (Figs.  120-121)  as  a  protection,  and  after  nursing 
the  fissures  or  abraded  areas  are  painted  with  bismuth  and  cas- 
tor oil  paste ;  compound  tincture  of  benzoin ; 
balsam  of  Peru ;  argyrol,  silver  nitrate  or 
sometimes  only  alcohol.  The  application  is 
made  with  sterile  swabs  prepared  by  tAvisting 
a  wisp  of  cotton  about  the  end  of  a  toothpick. 
If  the  crack  or  abrasion  is  extensive  enough 
to  cause  bleeding,  even  nursing  through  a 
shield  is  sometimes,  but  not  necessarily  dis- 
continued, while  the  other  treatment  is  the 

Fig.  121. — Nipple      same  as  for  a  nipple  that  does  not  bleed. 

shield   used   in   Fig.  „  ,  •     •         j      •       i        xi  ^     u 

"1^20  bound,  uninjured  nipples,  then,  are  to  be 

kept  clean  and  protected  from  infection  and 
those  which  are  abraded  or  cracked  are  to  be  kept  clean  and  also 
protected  against  further  injury. 

Lactation.  About  the  third  or  fourth  day  after  delivery, 
when  milk  replaces  colostrum,  the  breasts  become  swollen,  en- 
gorged and  often  very  painful,  and  not  infrequently,  a  hard, 
sensitive  lump  or  "cake"  may  be  felt.  The  growing  tendency, 
now,  is  merely  to  support  these  heavy  breasts  by  means  of  a 
binder  which  has  straps  passing  over  the  shoulders,  in  order  to 
hold  them  up  without  making  pressure  (Fig.  122)  and  to  apply 
ice  caps  or  hot  compresses  to  the  painful  areas.  It  used  to  be 
customary  to  massage  and  pump  caked  breasts,  to  apply  pressure 
and  various  kinds  of  lotions  or  ointments.  Though  one,  or  all  of 
these  measures  are  still  employed,  in  some  eases,  the  general  prac- 
tice is  to  avoid  manipulating  the  breasts  but  to  empty  them  reg- 
ularly by  the  baby 's  nursing ;  support  them  and  allow  Nature  to 
make  an  adjustment  between  the  amount  secreted  and  the 
amount  withdrawn. 


CARE  DURING  THE  NORMAL  I'UEHI'ERIUM      343 

Free   purging  is   sometimes   employed   and   tlie   amount   of 
fluids  reduced  until  the  engorgement   and  discomfort  subside. 


Fig.  122. — A  simple  method  of  supporting  heavy  breasts  by  means  of 
three  folded  towels;  one  fastened  about  the  waist,  one  over  each  shoulder, 
crossing  front  and  back. 


This  happy  issue  is  practically  always  reached  if  the  baby  nurses 
regularly  and  satisfactorily,  as  there  is  a  spontaneous  adjustment 
between  the  amount  secreted  by  the  mother  and  that  withdrawn 


344 


OBSTETRICAL  NURSING 


by  the  baby.  But  as  abscesses  may  follow  in  the  Avake  of  caked 
breasts,  particularly  if  the  nipples  are  sore,  it  is  of  great  im- 
portance that  the  nurse  watch  closely  for  the  first  evidence  of 
painful  lumps.  The  prompt  application  of  a  supporting  bandage 
and.  ice  bags  (Fig.  123)  or  hot  corapresses  will,  in  the  majority 


Fig.  123. — Ice  caps  held  in  place  on  painful  breasts  by  straight  binder 
with  darts  pinned  in  under  breasts  and  supported  by  shoulder  straps  of 
muslin  bandage. 

of  cases,  give  speedy  and  complete  relief.  So  widely  is  this  be- 
lieved that  many  doctors  regard  the  care  of  the  breasts,  including 
the  prevention  of  breast  abscesses,  as  a  nursing  question,  entirely, 
and  conversely  are  likely  to  regard  the  occurrence  of  a  breast 
abscess  as  an  evidence  of  careless  nursing. 

Certain  it  is  that  breast  abscesses  are  almost  never  seen  where 


CARE  DURING  THE  NORMAL  PUERPERIUM     345 

the  nurses  have  this  sense  of  responsibility,  and  habitually 
watch  the  breasts  closely  and  promptly  use  support  and  either 
heat  or  cold  when  the  breasts  become  heavy  and  sensitive. 

There  are  innumerable  bandages  and  methods  for  supporting 
heavy  breasts,  any  one  of  which  is  efficacious  so  long  as  it  meets 
the  two  chief  requirements:  to  lift  the  breasts,  suspending  their 
weight  from  the  shoulders,  and,  while  fitting  snugly  below  to 
avoid  making  pressure  at  any  point,  particularly  over  the  nipples. 
One  of  the  most  satisfactory  and  widely  used  supports  is  the  Y- 


FiG.  124. — Modified  Richardson  "Y"  binder  made  of  two  strips  of 
soft  muslin,  full  width  of  material  and  44  inches  lon<i,  folded  into  strips 
of  same  width  as  distance  from  margin  of  patient 's  breast  to  outer  part 
of  areola.  One  strip  is  folded  in  the  middle  at  right  angles  and  pinned  to 
one  end  of  the  other  strip  as  indicated.  (Figs.  124,  125,  126,  with  captions, 
are  from  The  Maternity  Hospital,  Cleveland,  by  courtesy  of  Miss  Calvin 
MacDonald.) 

bandage,  (Figs.  124,  125,  126),  another,  the  Indian  binder  (Fig. 
127.) 

The  nurse  must  on  no  account  massage  or  pump  engorged 
breasts  on  her  own  responsibility,  for  tliere  is  a  good  deal  of  evi- 
dence to  show  that  any  such  manipulation  tends  to  increase  the 
amount  of  the  secretion  and  this  in  turn  increases  the  engorge- 
ment and  pain.  It  is  possible,  too,  that  massage  may  bruise  the 
breasts  and  thus  make  them  more  susceptible  to  infection. 

Mastitis.     When    infection    occurs,    the    swollen,    painful 


346 


OBSTETRICAL  NURSING 


breasts  may  groAV  hot  and  red,  the  patient  may  complain  of  chil- 
liness and  have  a  slight  fever,  with  or  without  there  being  an 
abscess.     Even  then  the  general  treatment  is  most  frequently 


Fig.  125. — Bandage  in  Fig,  124  applied.  The  long  arm  of  binder  is 
placed  under  patient 's  shoulders,  one  end  of  the  Y  being  brought  around 
the  top  of  the  breasts  and  the  other  around  the  lower  part,  toward  the 
nurse,  crossed  at  right  angles  under  the  arm  and  pinned  to  long  arm  of 
liandage  as  indicated  in  F?g.  126.  The  nip])les  are  covered  with  sterile 
gauze  and  the  upper  and  lower  parts  of  the  Y  fastened  with  a  safety  pin 
between  the  breasts.  The  remaining  length  of  the  long  arm  is  brought 
across  the  breasts  and  fastened  with  a  safety-pin  to  the  opposite  side. 
When  the  baby  nurses  this  pin  is  removed  as  Avell  as  the  one  between  the 
breasts.  The  entire  binder  should  be  snug  and  held  in  place  by  means  of 
shoulder  straps,  pinned  front  and  back. 

found  to  consist  of  support ;  ice  or  heat ;  catharsis  and  restricted 
fluids,  though  in  some  cases  the  breasts  are  pumped  and  nursing 
is  discontinued. 

AVhen  the  inflammation  so  far  progresses  as  to  require  that 


CARE  DURING  THE  NORMAL  PUERPERIUM      347 

the  breast  be  opened  and  drained,  the  subsequent  nursing  care 
will  be  outlined  by  the  doctor  to  meet  the  needs  of  each  case.  It 
is  a  painful  operation  and  often  a  serious  one,  for  the  destruc- 


FlG.  126. — Y  bandage  in  Fig.  125  seen  from  the  opposite  side. 

tion  of  breast  tissue  may  be  extensive  enough  to  render  the 
breasts  valueless  as  milk-producing  organs.  The  healing  is  slow 
and  altogether  the  occurrence  is  a  most  lamentable  one. 

The  nurse's  part  in  preventing  this  complication  is  cleanli- 
ness and  gentleness  in  her  attentions ;  unremitting  watchfulness ; 
immediate  application  of  a  suspensory  bandage  and  either  heat  or 


Fig.  127. — Indian  Binder  used  at  The  Montreal  Maternity  Hospital  for 
supporting  heavy  breasts.       The  tapering  ends  tie  in  a  knot  in  front. 

cold,  upon  the  first  sign  of  engorgement  and  prompt  reporting 
to  the  doctor. 

If  the  patient 's  nipples  have  not  been  toughened  during  preg- 


348 


OBSTETRICAL  NURSING 


nancy  or  if  flat  or  retracted  nipples  have  not  been  satisfactorily 
brought  out,  it  may  be  necessary  for  the  nurse  to  employ  the 
treatment  to  these  ends  which  were  described  in  the  chapter  on 
pre-natal  care.  In  the  meantime  the  baby  may  have  to  nurse 
through  a  shield  until  the  nipple  is  brought  out  prominently 
enough  for  him  to  grasp  it  well. 

Stripping.  Sometimes  in  cases  of  depressed  nipples,  which 
the  baby  cannot  grasp,  or  when  the  baby  is  too  feeble,  to  nurse 
at  the  breast,  milk  is  withdrawn  from  the  breast  by  means  of  so- 
called  ** stripping."  The  nurse  should  scrub  her  hands  thor- 
oughly with  hot  water  and  soap  and  dry  them  on  a  sterile  towel 


Pig.  128. — Position  of  thumb  and  finger  below  nipple  on  areola,  in 
stripping  breasts.  (From  photograph  taken  at  The  Long  Island  College 
Hospital.) 

before  beginning.  The  breast  is  grasped  by  placing  the  thumb 
and  forefinger  of  the  right  hand  on  the  areola  on  opposite  sides  of 
the  nipple  but  well  below  it.  The  nipple  is  then  raised  from 
the  breast  by  a  quick,  lifting  and  rolling  motion  of  the  thumb 
and  finger,  accompanied  by  slight  pressure.  A  sterile  medicine 
glass  should  be  held  in  position  to  receive  the  milk  which  spurts 
from  the  nipple,  but  the  glass  should  not  touch  the  breast.  (Fig. 
128.) 

There  is  a  knack  about  stripping  and  it  requires  practice,  but 
those  doctors  who  advocate  it  feel  that  it  empties  the  breast, 
when  this  is  necessary,  with  less  disturbance  than  that  caused 
by  pumping,  and  as  the  milk  is  projected  directly  from  the  nip- 


CARE  DURING  THE  NORMAL  PUERPBRIUM     349 

pie  into  the  sterile  glass,  without  any  of  it  running  over  the 
nipple  or  breast  as  may  happen  in  pumping,  it  has  the  additional 
advantage  of  always  being  sterile. 

Extreme  gentleness  must  be  used;  the  openings  of  the  milk 
ducts  must  not  be  touched  by  the  fingers,  and  the  thumb  and 
finger  must  not  press  deeply  enough  to  reach  the  glandular  tis- 
sue itself.  If  done  properly  stripping  neither  stimulates  nor 
bruises  the  breast  tissue  nor  does  it  cause  the  patient  even  tem- 
porary discomfort. 

Abdominal  Binders  and  Bed  Exercises.  There  is  consid- 
erable dififercnee  of  oi)inion  about  the  advantage  of  using  ab- 
dominal binders  upon  the  puerperal  patient  while  she  is  in  bed, 
and  the  nurse  Avill  accordingly  care  for  the  patients  of  some 
doctors  who  use  them  and  for  those  of  others  who  do  not. 

The  application  of  a  moderately  snug  binder  for  the  first  day 
or  two  is  a  fairly  common  practice,  for  multi parse,  particularly, 
are  often  made  very  uncomfortable  by  the  sudden  release  of  ten- 
sion on  their  flabby  abdominal  walls ;  a  discomfort  which  a  binder 
will  relieve.  And  during  the  first  few  days  after  the  patient  gets 
up  and  walks  about,  she  is  sometimes  given  great  comfort  by  a 
binder  that  is  put  on  as  she  lies  on  her  back,  and  is  adjusted 
snugly  about  her  hips  and  the  lower  part  of  her  abdomen. 

But  the  continued  use  of  a  binder  after  the  first  day  or  two, 
while  the  patient  is  still  in  bed,  is  not  as  general  as  it  formerly 
was.  Many  women  ask  for  binders  in  the  belief  that  they  help 
to  ''get  the  figure  back"  to  its  original  outline,  and  some  doctors 
feel  that  the  use  of  the  binder  is  helpful  in  restoring  the  tone 
to  the  abdominal  muscles,  which  amounts  to  about  the  same 
thing.  Both  the  straiglit  swathe  and  the  Scultetus  binder  are 
used  for  this  purpose  and  they  are  put  on  in  the  usual  manner; 
snugly  and  with  even  pressure,  but  not  tight  enough  to  bind. 

Those  doctors  who  disapprove  of  the  binder  believe  that  it 
interferes  with  involution  and,  by  making  pressure,  tends  to 
push  the  uterus  back  and  cause  a  retro-position,  in  addition  to 
retarding  instead  of  promoting  a  return  of  normal  tone  to  the 
abdominal  muscles. 

Accordingly,  they  instruct  their  patients  to  take  exercises,  in- 
stead of  wearing  binders,  and  they  have  these  exercises  started 


350 


OBSTETRICAL  NURSING 


while  the  patient  is  still  in  bed.  Their  adoption,  and  the  rate 
at  which  they  are  increased,  are  entirely  dependent  upon  the 
individual  patient 's  condition,  for  they  must  never  be  continued 
to  the  point  of  fatigue.  There  are,  therefore,  no  definite  rules 
laid  down,  concerning  these  exercises,  beyond  a  description  of 
the  positions  and  movements  themselves,  and  their  sequence. 

Those  which  are  taught  to  the  patients  at  the  Long  Island 
College  Hospital  are  so  simple,  and  evidently  productive  of  such 
happy  results  that  they  offer  excellent  examples  of  this  form  of 
treatment.    They  are,  of  course,  taken  only  by  the  doctor 's  order, 


Fig.  129. 

Figs.  129  to  135,  inclusive,  are  bed  exercises  taken  during  the  ptier- 
perium.  For  description  see  text.  (From  photographs  taken  at  The  Long 
Island  College  Hospital.) 

but  the  nurse's  intelligent  supervision  increases  their  effective- 
ness. 

The  general  purpose  of  tliese  exercises  is  to  strengthen  the 
abdominal  muscles,  thus  helping  to  prevent  a  large,  pendulous 
abdomen;  to  increase  the  patient's  general  strength  and  tone, 
just  as  exercise  benefits  the  average  person ;  to  promote  involu- 
tion; to  prevent  retro-version  and  in  a  measure,  increase  intes- 
tinal tone  and  thus  relieve  constipation.  To  accomplish  these 
much  to  be  desired  ends  the  exercises  must  be  taken  with  modera- 
tion and  judgment;  started  slowly;  increased  very  gradually 
and  constantly  adapted  to  the  strengtisof  the  individual  patient. 
Otherwise  they  may  do  more  harm  than  good.  In  the  average, 
uncomplicated  case  in  which  the  patient  is  doing  well,  she  usu- 


CARE  DURING  THE  NORMAL  PUERPERIUM      351 

ally  starts  the  chin-to-chest  exercise  from  twelve  to  twenty -four 
hours  after  delivery.  She  should  lie  flat  on  her  back  and  raise 
her  head  until  her  chin  rests  upon  her  chest.  (Fig.  129.)  If 
she  rests  her  hand  upon  her  abdomen,  she  will  feel  for  herself 
that  the  abdominal  muscles  contract,  and  accordingly  will  be 


^^^K'VJr^ 

^1 

:7f  ?l 

■i 

'1 

'1 

"'  .^"-''^v^ 

*.-      .  ,J 

iflJillk_£L 

'^t^l 

Fig.  130. 

disposed  to  continue  the  exercises  with  more  interest  and  confi- 
dence than  she  otherwise  might.  The  movement  is  repeated 
twenty-five  times,  morning  and  evening,  every  day,  and  con- 
tinued as  long  as  the  patient  is  in  bed. 

The  familiar,  deep-breathing  exercise  is  ordinarily  started 


Fig.  131. 


352 


OBSTETRICAL  NURSING 


on  the  third  or  fourth  day.  The  patient  should  lie  flat,  with  her 
arms  at  her  sides,  then  extend  them  straight  out  from  the 
shoulders  (Fig.  130),  raise  them  above  her  head  (Fig.  131)  and 
return  them  to  the  original  position.  This  is  repeated  ten  times 
morning  and  evening,  daily,  as  long  as  the  patient  is  in  bed. 


Fig.  132. 

The  one-leg-flexion  exercises  are  not  done  by  patients  Avith 
perineal  stitches,  but  in  other  cases  they  are  usually  started 
about  the  fifth  day.  The  thigh  is  flexed  sharply  on  the  abdomen 
and  leg  on  thigh  (Fig.  132),  then  extended  and  lowered  to  the 
bed.  This  is  repeated  ten  times,  with  each  leg,  morning  and 
evening  for  one,  or  possibly  two  days. 

The  next  exercise  replaces  the  one-leg-flexion  and  is  started 
after  the  latter  has  been  done  for  one  or  two  days,  according  to 


Fig.  133. 

the  strength  of  the  patient,  and  it  in  turn  is  continued  for  only 
one  or  two  days.  Both  thighs  are  sharply  flexed  on  abdomen 
and  legs  on  thighs  (Fig.  133),  then  extended  and  lowered  but 
not  far  enough  for  the  heels  to  rest  upon  the  bed  before  being 
flexed  again.    This  is  repeated  ten  times  morning  and  evening. 


CARE  DURING  THE  NORMAL  PUERPERTUM      353 

Next  is  the  exercise  for  which  the  leg-flexion  exercises  pre- 
pare the  patient,  and  which  are  discontinued  when  this  one  is 
adopted.  It  is  started,  as  a  rule,  about  the  seventh  day,  or  three 
or  four  days  before  the  patient  gets  up.  Both  legs  are  slowly 
lifted  to  a  position  at  right  angles  to  the  body  (Fig.  134)  and 


^ 


Fig,  134. 

slowly  lowered,  but  not  far  enough  for  the  heels  to  touch  the 
bed  (Fig.  135),  and  the  movement  repeated.  As  this  exercise  re- 
quires a  good  deal  of  effort,  it  must  be  taken  up  very  gradually, 
as  follows :  The  legs  should  be  raised  on  the  first  day,  once  in  the 
morning  and  twice  in  the  evening;  second  day,  three  times  in 


Fig.  135. 


the  morning  and  four  times  in  the  evening;  third  day,  five  times 
in  the  morning  and  six  times  in  the  evening  and  so  on,  if  the  pa- 
tient is  not  fatigued,  until  the  exercise  is  repeated  ten  times  each 
morning  and  evening.    It  is  continued  for  several  months. 

The  knee  chest  position  (Fig.  136)  is  intended  to  counteract 


354 


OBSTETRICAL  NURSING 


the  tendency  toward  retroversion,  from  which  so  many  women 
suffer  after  childbirth.  It  is  usually  started  about  the  seventh 
day  and  the  patient  begins  by  remaining  in  that  position  for 


Fig.  136. — Knee  chest  position. 

a  moment  or  two,  gradually  lengthening  the  time  to  about  five 
minutes  each  morning  and  evening  for  about  two  months. 

"Walking  on  all  fours  is  violent  exercise  and  has  to  be  taken 
up  very  gradually.  Some  patients  are  able  to  attempt  it  on 
the  first  day  out  of  bed,  if  they  have  been  taking  the  other 


Fig.  137. — Walking  on  all  fours.     (From  a  photograph  taken  at  the 
Long  Island  College  Hospital.) 

exercises,  but  as  a  rule  it  is  not  started  until  the  second  or  third 
day.  The  patient 's  clothes  should  be  free  from  all  constrictions ; 
the  knees  should  be  held  stiff  and  straight  with  the  feet  widely 


CARE  DURING  THE  NORMAL  PUERPERIUM     355 

separated,  to  allow  a  rush  of  air  into  the  vagina,  and  the  entire 
palmar  surface  of  the  hands  should  rest  flat  on  the  floor.  (Fig. 
137.)  The  patient  should  start  by  taking  only  a  few  steps  each 
morning  and  evening,  gradually  lengthening  the  walk  to  five 
minutes  twice  daily  and  continuing  it  for  about  two  months. 

It  is  believed  that  as  the  patient  walks  in  this  position  the 
uterus  and  rectum  rub  against  each  other  producing  something 
the  same  result  as  would  be  obtained  by  massage.  The  effect  of 
the  exercise  is  to  promote  involution  and  diminish  the  tendency 
toward  constipation  and  retroversion,  apparently  preventing 
malposition  entirely  in  a  large  percentage  of  eases.  Though  not 
widely  used,  its  beneficial  effects  are  unquestioned  by  those  doc- 
tors who  employ  it. 

In  taking  a  general  survey  of  the  young  mother  and  her  needs, 
we  realize  that  in  a  broad  sense  she  is  not  ill,  in  so  far  as  no 
pathological  condition  exists.  But  she  is  in  a  transitional  state 
and  may  become  acutely  or  chronically  ill  if  not  carefully  watched 
and  nursed.  In  general  her  mental,  physical  and  nervous  forces 
must  be  conserved  and  increased,  and  this  requires  thoughtful 
and  devoted  attention  from  the  nurse.  She  must  be  scrupulously 
clean  in  her  care  of  the  nipples  and  perineum,  and  in  order  to  be 
able  promptly  to  inform  the  doctor  of  any  departure  from  the 
normal  in  the  patient's  condition,  the  nurse's  watchfulness 
should  embrace  regular  observations  upon  the  following : 

1.  The  patient's  general  condition ;   the  amount  and  character  of 
her  sleep;  her  appetite;  her  nervous  and  mental  condition. 

2.  The  temperature,  pulse  and  respiration. 

3.  The  height  and  consistency  of  the  fundus. 

4.  The  quantity,  color  and  odor  of  the  lochia. 

5.  The  persistence  and  severity  of  the  after-pains. 

6.  The  condition  of  the  perineum. 

7.  The  condition  of  the  nipples  and  breasts. 

8.  The  functions  of  the  bladder  and  bowels. 

If  all  goes  well  and  there  are  no  complications,  the  patient 
will  usually  be  able  to  assume  full  charge  of  her  baby  by  the 
sixth  or  eighth  week,  and  practically  return  to  her  customary 
mode  of  living,  with  the  difference  that  she  now  has  the  care  of 
a  baby  which  she  did  not  have  before.    The  care  of  that  baby 


356  OBSTETRICAL  NURSING 

requires  certain,  definite  care  of  herself,  as  a  nursing  mother, 
which  will  be  described  in  detail  in  the  next  chapter. 

To  sum  up  the  general  principles  of  nursing  the  young  mother 
during  the  puerperium,  we  find  that  just  as  during  pregnancy 
and  labor,  the  nurse  must  first  be  familiar  with  the  normal 
changes  that  occur  in  order  that  she  may  recognize  the  abnor- 
mal. Then,  as  before,  the  nurse's  care  of  the  individual  patient 
must  rest  unfailingly  upon  a  foundation  of  cleanliness  in  order 
to  prevent  infection;  watchfulness,  which  implies  ability  to 
recognize  normal  changes  and  unfavorable  symptoms;  adjust- 
ment to  the  methods  of  the  attending  physician  and  to  all  of 
the  circumstances  surrounding  the  patient,  and  the  wisest  and 
tenderest  consideration  for  her  patient  as  an  individual 


CHAPTER  XVI 

THE  NURSING  MOTHER 

Not  infrequently  tlie  nurse  remains  with  her  patient  after 
the  end  of  the  puerperium,  and  therefore  she  may  have  the  care 
of  the  mother  and  baby  for  several  weeks,  or  even  months.  The 
most  valuable  single  service  which  she  can  perform  in  this 
capacity  is  to  help  in  making  it  possible  for  the  mother  to  nurse 
her  baby  at  the  breast.  For  both  the  nurse  and  the  mother  must 
realize  that  the  breast-fed  baby  is  much  more  likely  to  live 
through  the  difficult  first  year,  and  is  markedly  less  susceptible 
to  disease  and  infection  than  is  the  bottle-fed  baby. 

The  first  step  is  to  convince  the  young  mother  of  what  it 
means  to  her  baby  and  her  obligation  to  try  to  nurse  him,  since, 
excepting  under  very  rare  and  unusual  conditions,  she  can  nurse 
him  if  she  wants  to  enough  to  make  the  necessary  effort  and 
sacrifice. 

The  important  contra-indications  for  attempting  breast-feed- 
ing are  retracted  nipples,  tuberculosis,  eclampsia,  severe  heart 
or  kidney  disease  and  certain  acute  infectious  diseases  such  as 
typhoid  fever. 

It  seldom  happens  that  the  mother  who  has  had  average  pre- 
natal care,  followed  by  good  care  during  and  after  delivery,  is 
unable  to  nurse  her  baby  if  she  orders  her  life  in  the  way  that  is 
known  to  be  necessary  to  promote  and  maintain  lactation.  The 
first  essential  is  her  real  desire  to  nurse  her  baby ;  next,  her 
appreciation  of  the  continuous  care  of  herself  that  is  necessary 
and  third,  her  whole-hearted  willingness  to  take  this  care  for 
her  baby's  sake. 

It  is  safe  to  say  that  if  the  doctor  and  the  nurse  and  the  pa- 
tient all  want  the  baby  to  nurse  at  the  breast,  and  all  do  every- 
thing in  their  power  to  make  this  possible,  they  will  almost  in- 
variably succeed.    This  assertion  can  scarcely  "be  made  too  posi- 

367 


358  OBSTETRICAL  NURSING 

tively,  ?nd  the  nurse  should  never  lose  sight  of  the  fact  that  if 
the  baby  is  not  breast-fed  he  is  being  defrauded,  and  in  the  vast 
majority  of  cases,  because  of  insufficient  effort  on  the  part  of 
the  doctor,  nurse  or  patient,  or  all  three. 

A  favorable  frame  of  mind  and  state  of  good  nutrition  in 
the  mother  are  the  two  indispensable  factors  in  establishing 
breast-feeding  and  in  maintaining  the  secretion  of  an  adequate 
supply  of  breast-milk.  These  conditions,  in  turn,  are  both  af- 
fected by  her  general  mode  of  living,  as  long  as  the  baby  nurses. 

Women  with  happy,  cheerful  dispositions  usually  nurse  their 
babies  satisfactorily,  while  those  who  worry  and  fret  are  likely 
to  have  an  insufficient  supply  of  milk,  or  milk  of  a  poor  quality. 
And  in  addition  to  this  sustained  influence,  the  temporary  effect 
of  a  fit  of  temper;  of  fright;  grief;  anxiety  or  any  marked  emo- 
tional disturbance  is  frequently  injurious  to  the  quality  of  milk 
that  previously  has  been  satisfactory.  Actual  poisons  are  created 
by  such  emotions  and  may  affect  the  baby  so  unfavorably  as  to 
make  it  advisable  to  give  him  artificial  food,  for  the  time  being, 
and  empty  the  breasts  by  stripping  or  pumping,  before  he  re- 
sumes breast  feeding. 

A  mother's  lack  of  faith  in  her  ability  to  nurse  is  so  detri- 
mental in  its  effect  that  she  must  be  assured  over  and  over,  that 
she  can  nurse  her  baby  if  she  will  persevere.  If  the  nursing  does 
not  go  well  at  first  she  must  not  give  up,  but  must  continue  to  put 
the  baby  to  the  breasts  regularly,  as  this  is  the  best  means  of 
stimulating  them  to  activity.  His  feeding  should  be  supple- 
mented with  modified  cow 's  milk,  if  the  breast  milk  is  inadequate 
either  in  amount  or  quality. 

Method  of  Nursing.  The  baby  should  be  put  to  the  breast 
for  the  first  time  between  eight  and  twelve  hours  after  he  is  born. 
This  gives  the  tired  mother  an  opportunity  to  rest  and  sleep,  and 
the  baby,  too,  is  benefited  by  being  kept  warm  and  quiet  during 
this  interval.  His  need  for  food  is  not  great  as  j'^et,  nor  is  there 
much  if  any  nourishment  available  for  him. 

In  preparing  to  nurse  her  baby,  the  mother  should  turn 
slightly  to  one  side,  and  hold  the  baby  in  the  curve  of  her  arm 
so  that  he  may  easily  grasp  the  nipple  on  that  side.  She  should 
hold  her  breast  from  the  baby 's  face  with  her  free  hand  by  plac- 


THE  NURSING  MOTHER 


359 


ing  the  thumb  above  and  fingers  below  the  nipple,  thus  leaving 
his  nose  uncovered,  to  permit  his  breathing  freely.  (Fig.  138.) 
The  mother  and  baby  should  lie  in  such  positions  that  both  will 
be  comfortable  and  relaxed,  and  the  baby  will  be  able  to  take  into 
h^  mouth,  not  only  the  nipple  but  the  areola  as  well,  so  as  to 


Fig.  138. — Position  of  mother  and  baby  for  nursing  in  bed. 


compress  the  base  of  the  nipple  with  his  jaws  as  he  extracts  the 
milk  by  suction. 

The  nurse  may  have  to  resort  to  a  number  of  expedients  in 
persuading  the  baby  to  begin  to  nurse,  for  he  does  not  always 
take  the  breast  eagerly  at  first.  He  must  be  kept  awake  and 
sometimes  suckling  will  be  encouraged  by  patting  or  stroking 
his  cheek.  Or  if  his  head  is  drawn  away  from  the  breast,  a  little, 
he  will  sometimes  take  a  firmer  hold  a)Kl  begin  to  nurse.  Moisten- 
ing the  nipple  by  expressing  a  few  drops  of  colostrum  or  with 


360  OBSTETRICAL  NURSING 

sweetened  water  may  stimulate  the  baby's  appetite  and  thus 
prompt  him  to  nurse. 

The  young  mother  must  be  prepared  to  find  very  discour- 
aging the  early  attempts  to  induce  the  baby  to  nurse,  but  if 
the  nurse  will  help  her  to  persevere  in  making  regular  attempts 
she  will  almost  certainly  succeed. 

During  the  first  two  or  three  days  the  baby  obtains  only 
colostrum,  while  nursing,  but  the  regular  suckling  is  extremely 
important,  not  alone  for  the  sake  of  getting  him  into  the  habit 
of  nursing  but  for  the  sake  of  stimulating  the  breasts  to  secrete 
milk. 

Moreover,  the  irritation  of  the  nipples  so  definitely  promotes 
involution  of  the  uterus  that  this  process  goes  on  more  rapidly 
in  women  who  nurse  their  babies  than  in  those  who  do  not.  If 
the  nipples  are  not  sufficiently  prominent  for  the  baby  to  grasp 
them,  a  shield  will  have  to  be  used  while  they  are  being  brought 
out.  But  the  shield  should  be  discarded  as  soon  as  possible  for 
it  is  the  baby's  suckling  that  produces  the  physiological  effects. 
If  a  shield  is  used,  it  should  be  washed  and  boiled  after  each 
use  and  kept,  between  nursings,  in  a  sterile  jar  or  a  solution 
of  boracic  acid. 

The  length  of  the  nursing  periods  and  the  intervals  between 
them  have  to  be  adjusted  to  the  needs  and  condition  of  each 
baby;  his  weight,  vigor,  the  rapidity  with  which  he  nurses,  the 
character  of  his  stools  and  his  general  condition,  all  of  which 
will  be  considered  in  connection  with  the  care  of  the  baby.  The 
intervals  between  nursings  are  measured  from  the  beginning  of 
one  feeding  to  the  beginning  of  the  next,  and  are  fairly  uniform 
for  babies  of  the  same  age  and  weight.  The  length  of  the  nurs- 
ing period  itself  is  usually  from  ten  to  twenty  minutes. 

The  average  baby  nurses  about  every  six  hours  during  the 
first  two  days,  or  four  times  in  twenty-four  hours.  According 
to  one  schedule  he  will  nurse  every  three  hours  during  the  day 
for  about  three  months,  beginning  with  the  third  day,  and  at 
10  p.m.  and  2  a.m.,  or  seven  times  in  twenty  four  hours.  From 
the  third  to  the  sixth  month  he  nurses  every  three  hours  during 
the  day  and  at  ten  o'clock  at  night,  or  six  times  in  twenty- four 
hours,  and  from  that  time  until  he  is  weaned  he  should  nurse  at 


THE  NURSING  MOTHER 


361 


Fig.   139. — The  Nursing   Mother.      (By  permission  from   a   pastel  by 
Gari  Melchers.) 


362 


OBSTETRICAL  NURSING 


four  hour  intervals  during  the  day  and  at  ten  o'clock  at  night, 
or  five  times  daily,  as  follows : 


First  and  second  days. 
First  three  months.... 
Third  to  sixth  month. 
After  the  sixth  month 


Day 

6.. 12..   G 
6..   9. .12. .3. .6 
6..   9..12..3..b 
6. .10..   2. .6 


Night 

12 

10.. 2  a.m. 

10. 

10. 


It  is  becoming  more  and  more  common  to  omit  night  feed- 
ings after  10  p.m.,  even  during  the  first  three  months,  with  the 
average  baby  who  is  in  good  condition.  When  this  practice  is 
adopted  the  baby  not  only  seems  to  do  as  well  as  he  normally 
should,  but  to  benefit  by  the  long  digestive  rest  during  the  night. 
Certainly  the  mother  profits  by  the  unbroken  sleep  which  this 
makes  possible. 

As  a  rule  the  baby  should  nurse  from  one  side,  only,  at  each 
nursing,  emptying  the  breasts  alternately,  but  if  there  is  not 
enough  milk  in  one  breast  for  a  complete  feeding  both  breasts 
may  be  used  at  one  nursing.  Neither  the  mother  nor  the  baby 
should  be  permitted  to  sleep  while  he  is  at  the  breast,  but  he 
should  pause  every  four  or  five  minutes  to  keep  from  feeding 
too  rapidly. 

After  the  mother  sits  up,  she  may  occupy  a  low,  comfortable 
chair  while  nursing  the  baby.  She  should  lean  slightly  forward 
and  raise  the  knee  upon  which  the  baby  rests  by  placing  her 
foot  on  a  stool,  supporting  his  head  in  the  curve  of  her  arm,  and 
holding  her  breast  from  his  face,  just  as  she  did  while  in  bed. 
(Fig.  139.)  She  should  nurse  him  in  a  quiet  room  where  she 
will  not  be  disturbed  nor  interrupted  and  where  the  baby  and 
her  breasts  will  be  protected  from  drafts  or  from  being  chilled. 
Many  women  prefer  always  to  lie  down  when  nursing  the 
baby. 

Before  the  nurse  leaves  her  patient  she  should  teach  her  how 
to  care  for  her  nipples,  including  the  preparation  of  boric  solu- 
tion ;  the  importance  of  washing  her  hands  before  bathing  her 
nipples,  and  of  keeping  the  breasts  covered  with  clean  gauze 
between  nursings. 


THE  NURSING  MOTHER  363 

PERSONAL  HYGIENE  OF  THE  NURSING  MOTHER 

The  personal  hygiene  of  llie  nursing  mother  slioukl  be 
virtually  a  continuation  of  that  which  is  advisable  during  the 
latter  part  of  the  puerperium;  a  normal,  tranquil  kind  of  life 
which  is  unfailingly  regular  in  its  daily  routine. 

But  this  is  not  quite  as  easy  as  it  sounds,  for  during  the  puer- 
perium the  young  mother  is  still  something  of  a  patient  and  is 
regarded  as  such,  while  during  the  months  that  follow  she  is 
simply  a  nursing  mother,  who  must  live  sanely  and  moderately 
for  her  baby's  sake,  and  at  the  same  time  take  her  place  among 
people  who  are  not  under  compulsion  to  place  any  special  re- 
strictions upon  their  daily  lives.  It  is  much  easier  to  take  pre- 
cautions and  follow  directions  for  a  few  days  or  weeks,  while 
the  situation  is  novel,  than  it  is  to  persist  month  after  month 
without  help  or  encouragement.  The  young  mother's  family 
often  fails  to  appreciate  the  difficulty  of  her  problem  and  for  this 
reason  she  is  sometimes  unable  to  care  for  herself,  as  she  should, 
with  the  result  that  she  cannot  nurse  her  baby  successfully. 

As  long  as  the  nurse  remains  with  her  patient,  therefore, 
she  must  try  to  impress  upon  both  the  patient  and  the  members 
of  her  household  that  the  most  important  single  factor  in  the 
care  of  the  new  baby  is  the  sustained  and  regular  care  which 
the  nursing  mother  should  take  of  herself.  For  it  must  be  re- 
membered constantly  that  it  is  not  alone  breast  feeding,  but 
satisfactory  breast  feeding  that  nourishes  and  builds  and  pro- 
tects the  baby.  Unsatisfactory  breast  milk  may  be  positively 
injurious,  and  irregularity  and  thoughtlessness  in  the  mother's 
mode  of  living  will  usually  produce  milk  of  this  character. 

Therefore,  for  ten  or  twelve  months  after  the  baby  is  born, 
the  mother  should  discharge  her  responsibility  and  obligation  to 
him  by  regulating  her  own  life  to  meet  his  needs. 

Diet.  Throughout  the  entire  nursing  period  the  mother's 
diet  must  be  such  that  it  will  nourish  her  and  also  aid  in  pro- 
ducing milk  which  will  meet  the  baby's  needs.  His  needs  are 
that  the  daily  demands  of  his  growing  body  shall  be  supplied 
and  that  he  shall  be  given  those  materials  which  will  build  a 
sound  body,  with  resistance  against  disease  and  infection. 


364  OBSTETRICAL  NURSING 

So  important  is  this  matter  of  nutrition,  and  the  principles 
upon  which  it  rests,  that  it  is  discussed  at  considerable  length 
in  the  succeeding  chapter.  At  this  point,  however,  it  may  be 
stated  briefly  that  the  most  valuable  article  in  the  nursing 
mother's  dietary  is  milk,  and  that  to  this  should  be  added  eggs 
and  the  vegetables  which  are  designated  as  ''leafy,"  and  fresh 
fruits,  particularly  oranges.  These  foods  are  rich  in  the  mate- 
rials which  are  essential  to  the  baby's  nutrition,  good  health, 
and  resistance. 

She  should  have  a  generous,  simple,  nourishing  mixed  diet, 
then,  consisting  largely  of  milk,  eggs,  and  leafy  vegetables.  She 
must  steadily  guard  against  indigestion  for  if  her  digestion  is 
deranged  the  baby  is  almost  sure  to  suffer.  Rich  and  highly 
seasoned  foods  must  be  avoided,  as  well  as  alcohol,  strong  tea  and 
coffee  or  any  articles  of  food  or  drink  that  might  upset  her. 

It  becomes  apparent  that  although  the  expectant  mother  does 
not  have  to  "eat  for  two,"  the  nursing  mother  does,  in  certain 
respects.  She  should  augment  the  nourishment  provided  by 
her  three  regular  meals,  by  taking  a  glass  of  milk,  cocoa  or  some 
beverage  made  of  milk,  during  the  morning,  afternoon  and  be- 
fore retiring. 

The  morning  and  afternoon  lunches  had  better  be  taken  about 
an  hour  and  a  half  after  breakfast  and  luncheon,  respectively, 
in  order  not  to  impair  the  appetite  for  the  meals  which  follow. 

It  is  very  important  that  the  nursing  mother  shall  take  her 
meals  with  clock-like  regularity  and  enjoy  them,  but  at  the  same 
time  she  must  guard  against  overeating,  for  fear  of  deranging 
her  digestion.  She  must  drink  water  freely,  partly  for  the  sake 
of  promoting  intestinal  activity. 

Bowels.  The  nursing  mother's  bowels  must  move  freely 
and  regularly  every  day,  but  she  should  not  take  cathartics  nor 
even  enemata  without  a  doctor's  order. 

She  will  usually  be  able  to  establish  the  habit  of  a  daily 
movement  by  taking  exercise,  eating  bulky  fruit  and  vegetables, 
drinking  an  abundance  of  water  and  regularly  attempting  to 
empty  her  bowels,  every  day,  preferably  immediately  after  break- 
fast. 

Rest  and  Exercise.     The  nursing  mother  will  not  thrive, 


THE  NURSING  MOTHER  365 

nor  will  the  baby,  unless  she  has  adequate  rest  and  sleep  and 
takes  at  least  a  moderate  amount  of  daily  exercise  in  the  open 
air.  She  should  have  eight  hours  sleep,  out  of  the  twenty-four, 
in  a  room  with  open  windows,  and  as  fatigue  has  an  injurious 
effect  upon  the  character  of  the  milk,  the  average  mother  should 
lie  down  for  a  while  every  afternoon. 

Her  exercise  will  have  to  be  adjusted  to  her  tastes,  customary 
habits,  circumstances  and  physical  endurance,  for  it  must  always 
be  stopped  before  she  is  tired.  Walking  is  often  the  best  form 
of  exercise  that  the  nursing  mother  can  take,  though  she  may 
engage  in  any  mild  sports  that  she  enjoys.  Violent  exercise  is 
inadvisable  because  of  the  exhaustion  that  may  follow. 

Recreation.  Part  of  the  value  of  exercise  lies  in  the  pleas- 
ure and  diversion  which  it  gives,  for  a  happy,  contented  frame 
of  mind  is  practically  indispensable  to  the  production  of  good 
milk.  In  addition  to  some  regular  and  enjoyable  exercise,  there- 
fore, the  mother  needs  a  certain  amount  of  recreation  and  change 
of  thought  and  environment.  If  her  life  is  monotonous  and 
colorless,  the  average  woman  is  likely  to  become  irritable  and 
depressed ;  to  lose  her  poise  and  perspective ;  to  worry  and  fret, 
and  then,  no  matter  what  she  eats  nor  how  much  she  sleeps,  her 
digestion  will  suffer,  her  milk  will  be  affected  and  the  baby  will 
pay.  This,  of  course,  goes  back  to  the  question  of  her  mental 
state  and  the  condition  of  her  nerves  as  being  determining 
factors  in  the  young  mother's  ability  to  nurse  her  baby  success- 
fully. 

For  the  sake  of  giving  her  an  opportunity  to  go  out,  mingle 
with  her  friends  or  enjoy  some  music  or  a  play,  it  is  often  a  very 
good  plan  to  replace  one  breast  feeding,  some  time  in  the  course 
of  each  day,  with  a  bottle  feeding.  The  freedom  which  this  long 
interval  between  two  nursings  gives  the  mother  for  diversion 
and  amusement,  will  usually  affect  her  general  condition  so 
favorably  that  the  quality  of  her  milk  is  better  than  it  other- 
wise would  be,  and  the  baby  is  benefited  as  a  result.  This  single 
supplementary  feeding  cannot  be  regarded  lightly,  however,  for 
it  must  be  prepared  with  the  same  cleanliness  and  accuracy  as 
an  artificial  diet. 

Weaning.     One  advantage  in  giving  the  baby  a  supplemen- 


366  OBSTETRICAL  NURSING 

tary  bottle,  once  a  day,  is  that  it  paves  the  way  for  -weaning, 
when  the  time  comes  to  make  this  change.  Under  ordinary  con- 
ditions, the  mother  begins  to  wean  her  baby  about  the  eighth  or 
tentli  month.  Having  started  by  replacing  one  breast  feeding, 
daily,  with  a  bottle  feeding,  she  should  gradually  increase  the 
number  of  daily  artificial  feedings  until  all  of  the  breast  feed- 
ings are  discontinued  by  the  time  the  baby  is  eleven  or  twelve 
months  old.  There  are  exceptions  to  this  general  rule,  of  course, 
and  under  any  conditions  the  weaning  should  always  be  directed 
by  a  doctor,  for  the  baby  will  suffer  unless  it  is  skillfully  done. 

If  the  mother's  milk  is  satisfactory  and  the  baby  is  doing 
well,  it  is  often  considered  wiser  not  to  discontinue  the  breast 
feeding  entirely,  during  the  hot  summer  months,  even  though 
the  weaning  falls  due  at  this  time. 

It  was  formerly  deemed  advisable  to  wean  the  baby  for  any 
one  of  several  reasons,  but  at  present  the  only  indications  for 
this  step  which  are  generally  accepted  by  the  medical  profes- 
sion, are :  pulmonary  tuberculosis,  acute  infectious  diseases  in 
the  mother,  and  pregnancy.  Menstruation,  which  is  normally 
suspended  during  lactation,  was  long  regarded  as  incompatible 
with  satisfactory  nursing,  but  it  is  now  known  that  if  the  mother 
is  taking  proper  care  of  herself  and  is  in  generally  good  condi- 
tion, the  effect  of  menstruation  upon  the  milk  is  usually  for  the 
duration  of  the  periods  only.  It  may  be  necessary  to  supple- 
ment the  breast  feeding  with  suitably  modified  cow's  milk  dur- 
ing menstruation,  but  the  baby  should  be  put  to  the  breast  regu- 
larly, just  the  same,  for  if  the  stimulation  of  the  baby's  suckling 
is  discontinued,  the  temporary  reduction  in  the  amount  of  milk 
secreted  will  probably  be  permanent. 

The  state  of  pregnancy,  however,  is  different,  for  though 
some  women  nurse  the  baby  satisfactorily  for  some  months  after 
becoming  pregnant,  it  is  not  considered  advisable  to  subject  a 
woman  to  the  combined  strain  of  pregnancy  and  nursing. 
Moreover,  the  mother's  milk  is  usually  impoverished  during 
pregnancy  and  the  nursing  baby  suffers  in  consequence. 

Drying  up  the  Breasts  used  to  be  a  great  bugbear.  Lotions, 
ointments  and  binders  were  employed  and  often  a  breast  pump 
as  well.     Various  drugs  were  given  by  mouth  and  the  patient 


THE  NURSING  MOTHER  367 

was  more  or  less  rigidly  dieted.  It  is  true  that  some  of  these 
measures  are  still  employed  and  are  followed  by  a  disappeararice 
of  the  milk.  But  at  the  same  time,  the  breasts  dry  up  quite  as 
satisfactorily  when  none  of  these  things  is  done,  provided  the 
baby  does  not  nurse.  It  is  not  known  what  starts  the  secretion  of 
milk  in  the  mother's  breasts  but  certain  it  is  that  absence  of  the 
baby's  suckling  prevents  it. 

If  the  drying  up  of  the  breasts  is  left  to  the  nurse,  as  it  so 
frequently  is,  her  wisest  course  will  be  to  do  nothing  beyond 
applying  a  supporting  bandage  if  the  breasts  are  heavy  enough 
to  be  uncomfortable.  She  may  rely  absolutely  upon  the  fact 
that  the  baby's  suckling  is  the  most  important  stimulation  in 
promoting  the  activity  of  the  breasts  and  if  this  stimulation  is 
not  given,  or  is  removed,  the  secretion  of  milk  will  invariably 
subside  in  the  course  of  a  few  days.  It  is  true,  that  the  breasts 
may  be  engorged  and  very  uncomfortable  for  a  day  or  two,  and  in 
addition  to  a  supporting  bandage  the  doctor  may  order  sedatives, 
but  the  discomfort  subsides  as  the  secretion  disappears.  This 
is  true  whether  the  reason  for  drying  up  the  breasts  is  that  the 
baby  is  still  born  or  has  died,  or  a  live  baby 's  nursing  is  discon- 
tinued. 

Naturally,  the  nurse  will  not  press  her  patient  to  drink  an 
extra  amount  of  milk  if  it  is  not  desirable  to  promote  the  activity 
of  the  breasts,  but,  unless  otherwise  ordered,  there  is  no  neces- 
sity for  placing  any  other  restrictions  upon  her  patient 's  diet. 

In  thinking  over  the  period  of  lactation,  as  a  whole,  it  is 
apparent  that  the  most  valuable  service  which  the  nurse  can 
offer  to  the  nursing  mother,  is  assistance  in  planning  and  living 
a  simple,  normal,  tranquil  life ;  helping  her  to  eat,  sleep,  bathe, 
and  exercise  and  to  nurse  lier  baliy  with  unfailing  regularity 
— all  for  the  sake  of  providing  her  baby  with  adequate  nourish- 
ment.    This  must  be  the  chief  end  and  aim  of  her  existence. 

Normal  breast-milk  is  the  ideal  baby  food  and  there  is  no 
entirely  satisfactory  substitute.  It  greatly  increases  the  baby's 
chances  of  living  through  the  first  year,  and  protects  him  from 
many  diseases. 

Quite  evidently,  breast-feeding  is  every  baby's  right  and  the 
nurse  can  and  should  help  him  to  secure  it. 


CHAPTER  XVII 
NUTRITION  OF  THE  MOTHER  AND  HER  BABY 

The  importance  of  providing  the  expectant  and  nursing 
mother  with  suitable  food  has  been  stressed  so  insistently  in  the 
preceding  pages,  that  it  is  advisable  to  explain  to  the  nurse  the 
reason  for  these  recommendations,  in  regard  to  certain  groups  of 
foods,  and  thus  make  clear  why  a  young  mother  may  eat  a  large 
amount  of  food  and  have  an  adequate  amount  of  breast  milk,  and 
yet  fail  to  nourish  her  baby  satisfactorily. 

The  following  material  is  available  in  these  pages  through 
the  interest  and  generosity  of  Dr.  E.  V.  McCollum  and  Miss 
Nina  Simmonds,  Professor  and  Assistant  Professor  of  Chemical 
Hygiene,  School  of  Hygiene  and  Public  Health,  Johns  Hopkins 
University.  This  information  is  the  result  of  many  years  of  re- 
search and  experimentation  on  many  thousands  of  laboratory 
animals  and  of  observations  upon  human  beings  as  well.  Dr. 
McCollum  and  Miss  Simmonds  offer  the  fruits  of  their  labors 
to  obstetrical  nurses,  in  the  belief  that  they  are  in  a  peculiarly 
favorable  position  to  aid  in  improving  the  nutritional  state  of 
the  coming  generation. 

In  order  that  such  a  discussion  may  not  seem  irrelevant  to 
obstetrical  nursing,  the  nurse  must  remind  herself  anew,  that 
the  object  of  obstetrics  to-day  is  not  only  to  carry  a  woman  safely 
through  childbirth,  but  to  give  her  such  care  from  the  begin- 
ning of  pregnancy  that  she  and  the  baby  shall  emerge  from 
this  experience,  not  merely  alive,  but  well  and  vigorous  and  with 
every  prospect  of  continuing  to  be  so. 

It  is  the  acknowledged  obligation  of  those  engaged  in  obstet- 
rical work  to  strive  toward  improving  the  health  of  the  race 
at  its  source — the  health  of  the  mothers  and  babies.  Malnour- 
ished mothers  and  malnourished  babies  do  not  develop  a  hardy 

race. 

368 


NUTRITION  OF  THE  MOTHER  AND  HER  BABY    369 

It  is  probably  safe  to  say  that  the  two  most  influential  factors 
in  creating  and  maintaining  a  satisfactory  state  of  health  are 
suitable  nutrition  and  prevention  of  infection ;  and  although 
we  shall  concern  ourselves  solely  with  nutrition  in  this  chapter, 
it  should  be  stated  in  passing  that  a  state  of  good  nutrition  goes 
far  toward  protecting  the  individual  from  infection. 

It  will  help  in  clarifying  the  subject  to  explain  in  the  begin- 
ning that  a  state  of  good  nutrition  is  not  necessarily  evidenced 
by  one's  being  tall  nor  by  being  fat.  But  it  is  evidenced  by  nor- 
mal size  and  development ;  sound  teeth  and  bones ;  hair  and  skin 
of  normal  color  and  texture ;  blood  of  the  normal  composition ; 
stable  nerves ;  vigor  both  mental  and  physical ;  normally  func- 
tioning organs  and  resistance  to  disease,  and  above  all  that  in- 
describable condition  which  is  summed  up  as  a  state  of  general 
well-being. 

That  this  degree  of  nutritional  stability  is  not  as  prevalent 
in  this  country  as  might  be  desired  is  disclosed  by  reports  upon 
findings  of  the  examining  boards  for  army  service,  over  a  period 
of  three  years  and  physical  examinations  of  various  groups  of 
school  children  throughout  the  country.  It  was  found  in  the 
first  case,  that  about  sixteen  per  cent,  of  the  apparently  normal 
young  men  who  were  inspected  for  military  service,  were  under- 
nourished in  some  degree,  and  according  to  Dr.  Thomas  W. 
"Wood,  Professor  of  Physical  Education,  Columbia  University, 
"Five  million  children  in  the  United  States  are  suffering  from 
malnutrition."  This  army  of  undernourished  children,  which 
represents  about  one-third  of  the  children  of  the  country,  is  on 
the  broad  highway  to  ill  health,  invalidism  of  various  kinds  and 
degrees,  instability  and  inefficiency.  They  are  certainly  not 
developing  into  the  clear-eyed,  alert,  buoyant  individuals  that 
go  to  make  up  good  citizenry. 

The  tragic  aspect  of  this  state  of  undernourishment  is  that 
though  a  great  deal  can  be  done  to  nourish  and  build  up  the 
malnourished  eliild  or  adult,  a  certain  amount  of  damage  that 
results  from  inadequate  nourishment  during  the  early,  forma- 
tive weeks  and  months  cannot  be  entirely  repaired  later  on  in 
life. 

As  the  baby   grows  and  develops,   certain   substances  are 


370  ■  OBSTETRICAL  NURSING 

needed  at  the  various  stages  of  its  progress,  and  if  these  are 
not  supplied  at  these  stages,  there  will  always  be  some  degree 
of  inadequacy  in  the  adult  make  up.  It  is  much  like  the  futility, 
when  building  a  house,  of  using  bricks  without  straw  for  the 
foundation  instead  of  firm,  dural)le  rock,  and  then  trying  to 
make  it  substantial  and  secure  later  on  by  using  good  materials 
when  constructing  the  upper  stories. 

The  solid  foundation  and  substantial  beams  and  girders  for 
men  and  women  are  put  in  during  infancy  and  early  childhood 
in  the  shape  of  good  material  that  forms  good  nerves,  muscles, 
bones,  teeth  and  general  physical  stability.  It  is  practically 
impossible  to  make  up  to  the  older  child  or  adult  for  damage 
caused  by  failure  to  supply  sufficient  nourishment  to  the  grow- 
ing,  developing,  infant  body. 

"The  moving  finger  writes;   and,  having  writ, 
Moves  on ;  nor  all  thy  piety  nor  wit 
Shall  lure  it  back  to  cancel  half  a  line, 
Nor  all  thy  tears  wash  out  a  word  of  it." 

We  see  all  about  us  the  results  of  this  form  of  neglect  of 
babies,  in  the  bow-legged,  knock-kneed,  undersized,  misshapen, 
chicken-breasted  adults  and  in  those  who  are  nervous  and  below 
par  in  endurance ;  are  susceptible  to  colds  and  other  infections 
and  may  be  summed  up  as  being  "not  strong." 

The  reasons  for  much  of  the  undernourishment  among  peo- 
ple in  this  country  to-day  are  to  be  found  in  certain  widespread 
misconceptions  of  long  standing  as  to  what  constitutes  a  state 
of  good  nutrition  or  malnutrition  and  the  value  and  purposes  of 
different  foodstuffs.  For  malnutrition  does  not  necessarily  de- 
scribe a  simple  condition  due  to  an  insufficient  amount  of  food, 
but  to  any  one  of  several  complex  conditions  due  to  a  lack  in 
the  food  of  one  or  more  essential  substances. 

One  may  eat  a  large  amount  of  food  and  even  have  a  well- 
padded  body  and  yet  be  seriously  in  need  of  certain  food  factors 
— in  other  words,  be  incompletely  nourished  in  some  particular. 

That  was  possibly  the  first  misconception — the  belief  that  one 
simply  needed  enough  food,  and  accordingly  was  well  nourished 
if  three  large  meals  were  eaten  daily,  irrespective  of  the  com- 
position of  those  meals.    A  step  forward  was  taken  when  house- 


NUTRITION  OF  THE  MOTHER  AND  HER  BABY    371 

wives  and  people  generally  accepted  the  fact  that  quantity  alone 
was  not  enough  to  consider  in  providing  food,  but  that  the  dietary 
should  consist  of  balanced  amounts  of  the  five  food  materials: 
fats,  carbohydrates,  proteins,  minerals  and  water,  in  order  to 
build  and  maintain  the  body  in  a  state  of  health. 

But  this,  too,  was  found  to  be  an  error,  in  so  far  as  it  was 
only  a  part  of  the  truth,  for  it  was  next  ascertained  that  even 
provision  for  a  suitable  balance  of  the  five  food  groups  was  not 
enough  to  nourish  us,  but  that  we  must  consider  the  heat  and 
energy  producing  properties  of  these  component  parts,  as  meas- 
ured by  the  caloric  unit,  and  each  must  daily  take  in  the  requisite 
number  of  calories  if  we  would  keep  our  engines  going. 

It  is  now  known  that  even  this  is  not  enough,  for  we  may 
eat  food  in  ample  quantities,  consisting  of  the  properly  balanced 
fats,  proteids,  carbohydrates,  minerals  and  water,  and  it  may 
daily  yield  the  required  number  of  calories,  and  still  we  may 
suffer  from  seriously  faulty  nutrition. 

Hess  and  Unger  state  in  this  connection,  that,  **in  framing 
dietaries  for  children  and  adults,  our  minds  are  still  focused  on 
insuring  a  sufficient  supply  of  calories  in  the  food,  and  we  have 
not  j^et  reacted  in  practice  to  the  newer  knowledge  that  ample 
carbohydrates,  fats  and  proteins  may  constitute  a  dangerously 
deficient  diet."  ^ 

"We  find  an  explanation  for  this  fact  in  the  comparatively 
recent  recognition  of  three  substances,  as  yet  not  clearly  under- 
stood, which  are  contained  in  a  certain  few  articles  of  food,  each 
one  of  which  is  essential  to  growth  and  normal  health  and  well- 
being,  though  not  necessarily  concerned  in  the  production  of 
heat  or  energy.  Various  terms  have  been  applied  to  these  mys- 
terious, but  necessary  substances,  such  as  vitamines,  accessory 
food  substances  as  applied  to  all,  or  fat-soluble  A,  water-soluble 
B  and  water-soluble  C  to  designate  them  separately. 

A  surprisingly  small  amount  of  each  of  these  substances  is 
sufficient  to  meet  the  needs  of  an  individual,  but  no  one  of  these, 
even  in  this  small  amount,  can  be  safely  dispensed  with,  for  if 
the  diet  is  deficient,  or  lacking  in  one  or  more  of  them  some 

^  Alfred  F.  Hess,  M.D.,  and  Lester  J.  Unger,  American  Journal  of  Dis- 
eases of  Children,  April,  1919. 


372  OBSTETRICAL  NURSING 

form  of  nutritional  disturbance  will  result.  It  may  be  severe 
enough  to  be  diagnosed  as  a  disease,  or  it  may  be  only  enough 
to  keep  the  individual  below  a  normal  state  of  health. 

When  the  disturbance  is  profound  enough  to  produce  a  defi- 
nite, recognizable  condition,  it  is  designated  as  a  deficiency  dis- 
ease, of  which  there  are  three :  scurvy,  beri-beri  and  xerophthal- 
mia. With  these  are  sometimes  included  rickets  and  pellagra. 
The  exact  cause  of  the  two  latter  disorders  is  not  definitely 
known  but  both  are  associated  with  faulty  nutrition.  Poor 
hygienic  conditions  may  enter  into  the  causation  of  rickets,  and 
infection  may  be  a  factor  in  the  occurrence  of  pellagra,  but 
neither  disease  appears  among  those  who  are  suitably  fed  while 
both  diseases  may  be  produced  by  faulty  diet  and  both  may  be 
cured  with  suitable  food. 

But  probably  of  graver  importance  to  the  public  welfare  than 
the  well  defined  nutritional  disturbances,  themselves,  is  the  fact 
that  between  a  state  of  good  health  and  the  level  upon  which  a 
disease  is  recognizable  is  a  long  scale,  along  which  are  ranged 
an  uncounted  army  of  under-par,  half-sick  people.  These  are 
the  ones  who  are  tired,  nervous,  susceptible  to  infections,  with 
feeble  recuperative  powers,  and  in  general  are  more  or  less  in- 
effective in  the  business  of  life. 

It  is  this  borderline  state,  or  as  Dr.  Goldberger  terms  it,  *  *  the 
twilight  zone,"  which  cannot  quite  be  called  disease  but  is  not 
health,  that  is  serious  to  the  masses,  for  diagnosed  disease  is 
given  treatment,  but  nervousness,  lack  of  energy  and  endurance, 
weakness  and  inefficiency  are  not  treated;  they  are  merely 
tolerated,  as  a  rule.  The  sufferers  fail  to  reach  their  highest 
possible  development  and  they  fail  to  be  of  highest  value  to 
society. 

This  is  the  condition  which  can  be  so  largely  prevented  by 
giving  the  baby  a  good  nutritional  foundation ;  this  must  be 
started  during  its  prenatal  life,  carried  through  the  nursing 
period  and  then  continued  throughout  the  rest  of  his  life.  Since 
the  nurse  is  very  likely  to  be  entrusted  with  the  arrangement  of 
the  patient's  dietary,  being  told  merely  to  give  a  liquid,  soft 
or  light  diet  and  possibly  to  avoid  certain  articles,  it  will  mean 
much  to  the  coming  generation  if  nurses  at  large  are  able  so  to 


NUTRITION  OF  THE  MOTHER  AND  HER  BABY  373 

compose  the  various  diets  for  the  expectant  and  nursing  mother, 
that  they  will  provide  not  only  the  requisite  fats,  proteids, 
carbohydrates,  minerals  and  water  and  yield  the  necessary 
calories,  but  also  contain  all  three  protective  substances :  fat- 
soluble  A,  water-soluble  B  and  water-soluble  C.  It  can  be 
demonstrated  that  when  these  food  factors  are  not  present  in 
the  mother's  diet,  they  will  not  appear  in  her  milk,  and  accord- 
ingly will  not  be  supplied  to  her  baby. 

This  is  the  crux  of  the  whole  matter.  If  the  mother's  diet  is 
faulty,  her  milk  will  be  faulty  in  the  same  respect  and  the  baby 
will  start  life  with  tissues  which  contain  an  inadequate  amount 
of  the  substances  that  are  necessary  to  make  them  sound  and 
promote  health. 

That  is  what  we  have  in  mind  when  we  say  that  the  mother's 
milk  must  be  satisfactory  not  alone  in  quantity  but  in  quality 
as  well. 

In  order  to  make  quite  clear  how  damaging  are  the  results 
of  diets  which  are  deficient  or  lacking  in  these  protective  sub- 
stances, we  shall  take  up,  briefly,  the  deficiency  diseases  in  turn. 

Scurvy  (scorbutus)  is  caused  by  a  lack  or  deficiency  of  the 
substance  called  water-soluble  C,  the  most  unstable  of  all  the 
protective  substances,  being  easily  impaired  or  destroyed  by 
heating,  drying  or  aging.  This  anti-scorbutic  substance  is  pres- 
ent in  fresh  milk,  potatoes,  oranges,  lemons,  onions,  and  such 
fresh  vegetables  as  lettuce,  raw  cabbage  and  celery  and  in  apples, 
pears,  peaches,  bananas  and  cantaloupe.  Tomatoes  are  rich 
in  the  anti-scorbutic  substance  and,  moreover,  this  form  is  but 
slightly  injured  by  heating  or  aging,  for  which  reason  canned 
tomatoes  are  frequently  used  both  to  prevent  and  to  cure  scurvy. 

Scurvy  is  a  disease  which  develops  slowly.  The  patient  loses 
weight,  is  anemic,  pale,  weak  and  short  of  breath.  The  gums 
become  swollen,  bleed  easily  and  frequently  ulcerate;  the  teeth 
loosen  and  often  drop  out.  Necrotic  areas  in  the  bones  may 
result.  Hemorrhages  into  the  mucous  membranes  and  the  skin 
are  characteristic.  Large  black  and  blue  spots  develop  in  the 
skin,  after  trivial  injury,  or  even  spontaneously.  The  ankles 
become  edematous  and  in  severe  cases  a  hard,  board-like  con- 
dition of  the  skin  and  subcutaneous  tissues  develops.     There,  is 


374  OBSTETRICAL  NURSING 

sometimes  severe  headache  and  in  the  later  stages  there  may  be 
convulsions  and  delirium. 

Although  scurvy  has  been  known  to  exist  for  centuries,  -well 
developed  cases  are  not  often  seen  among  adults  to-day,  because 
experience  has  taught  the  importance  of  including  some  fresh 
food  in  the  dietary,  and  present  transportation  facilities  make 
this  a  fairly  simple  matter  for  most  people.  The  disease  was 
doubtless  limited  almost  entirely  to  soldiers  and  pioneers  until 
after  the  discovery  of  America.  This  event  marked  the  begin- 
ning of  long  sailing  voyages,  with  diets  of  dried  and  otherwise 
preserved  foods,  and  scur-vy  began  to  take  a  heavj^  toll  of  life 
among  the  mariners.  It  became  known  as  "the  calamity  of 
sailors"  because  of  its  frequency  on  shipboard.  A  notable  in- 
stance in  the  history  of  the  disease  was  the  voyage  of  Jacques 
Cartier,  in  1536,  when  he  lost  twenty-six  of  his  party  from 
scurvy,  and  only  saved  the  remainder  by  the  use  of  an  infusion 
of  pine  needles.  The  efficacy  of  fresh  fruits  and  vegetables  in 
the  prevention  and  cure  of  scurvy  was  discovered  by  common 
experience ;  when  it  became  customary  to  administer  lime-  or 
lemon- juice  to  all  sailors,  scurvy  practically  disappeared  from 
the  service. 

Although  we  seldom  see  actual  cases  of  the  disease  among 
adults  to-day,  it  is  believed  that  there  are  large  numbers  of  bor- 
der-line eases  among  people  who  subsist  largely  on  meats,  canned 
and  dried  vegetables  and  canned  fruits,  the  meat-bread-and- 
potato  type  of  diet,  for  several  months  at  a  time,  as  during 
the  winter  season. 

''Every  individual  requires  a  certain  amount  of  anti-scor- 
butic substance  in  his  dietary,  or  to  put  this  statement  in  a 
broader  way,  every  nation  has  need  for  a  per  capita  quota  of 
foodstuffs  containing  this  necessary  food  factor,  if  scurvy  is  to 
be  avoided."  ^ 

Infantile  scurvy  is  seen  among  babies  who  are  fed  solely  on 
milk  that  has  been  heated,  boiled,  pasteurized  or  canned,  since 
the  anti-scorbutic  substance  in  milk  is  practically  destroyed 
by  heating  or  aging.     The  disease  is  characterized  by  malnutri- 

^  Alfred  P.  Hess,  M.D.,  The  Journal  of  the  American  Medical  Association, 
Sept.  21,  1918. 


NUTRITION  OF  THE  MOTHER  AND  HER  BABY    375 

tion,  pain,  typical  changes  in  the  structure  of  the  bones  and 
hemorrhage  in  various  parts  of  the  body,  most  frequently  in  the 
gums  and  beneath  the  periosteum.  The  disease  develops  slowly, 
the  first  symptoms  appearing  between  the  seventh  and  tenth 
months.  Tenderness  or  pain  in  the  legs  is  perhaps  the  most 
common  symptom  and  may  be  detected  first  by  the  baby 's  crying 
when  its  diaper  is  changed  or  its  stockings  are  put  on.  And  a 
baby  that  previously  has  been  cheerful,  playful  and  active  will 
prefer  to  lie  quietly  and  will  cry  whenever  it  is  touched.  He 
grows  pale,  listless  and  weak  and  fails  to  gain  in  weight  or 
length.  The  large  joints  are  likely  to  be  swollen  and  tender; 
the  swollen  gums  may  bleed;  the  urine  may  be  diminished  in 
amount  and  contain  blood  and  there  also  may  be  edema.  But 
it  is  quite  possible  for  a  baby  to  be  in  serious  need  of  an  anti- 
scorbutic and  still  not  present  well  defined  symptoms  of  seur\'y, 
or  it  may  suffer  from  the  latent  or  subacute  type  of  the  disease. 
In  the  latter  case  there  may  be  stationary  weight ;  fretfulness ; 
a  muddy  complexion ;  rapid  pulse  and  respirations ;  edema  over 
the  tibise  with  perhaps  tenderness  of  the  bones  and  tiny  hemor- 
rhagic areas  over  the  body. 

Scurvy  may  be  both  prevented  and  cured  by  giving  orange 
juice,  potato  water,  or  tomato  juice  to  a  baby  whose  diet  con- 
sists of  milk  that  has  been  heated  and  is  therefore  lacking  in 
water-soluble  C.  Many  doctors  believe  that  an  anti-scorbutic 
should  be  started  as  early  as  the  end  of  the  first  month,  with 
babies  fed  on  pasteurized  milk,  for  the  disease  develops  so  slowly 
that  severe  damage  may  be  done  if  the  administration  of  this 
material  is  delayed  until  symptoms  appear. 

Scurvy,  itself,  does  not  often  cause  death  among  babies,  but 
its  occurrence  is  serious  since  it  renders  the  infants  very  sus- 
ceptible to  infection,  particularly  nasal  diphtheria  and  "grip." 
Recovery  from  even  severe  attacks  is  amazingly  rapid,  sometimes 
being  complete  in  a  week  or  ten  days  as  a  sole  result  of  giving 
orange  juice. 

It  is  sometimes  recommended  that  modified  milk,  for  infant 
feeding,  be  made  up  with  potato  water,  instead  of  barley  water, 
since  the  latter  has  no  anti-scorbutic  properties,  while  potatoes 
are  somewhat  protective  even  after  being  cooked. 


376  OBSTETRICAL  NURSING 

Spinach  water  is  sometimes  given,  but  there  is  doubt  in  some 
minds  about  its  anti-scorbutic  value,  which  seems  to  be  more 
damaged  by  heat  than  that  of  potatoes  and  tomatoes. 

Canned  tomatoes  are  valuable  because  of  being  inexpensive 
and  preserving  their  anti-scorbutic  properties,  even  after  heat- 
ing. It  is  the  opinion  of  many  pediatricians  that  babies  tolerate 
canned  tomatoes  very  well,  and  in  some  cases  may  be  given  as 
much  as  four,  six,  or  even  eight  ounces  daily,  without  causing 
trouble. 

Infusion  of  orange  peel  also  is  used  in  the  prevention  and 
treatment  of  scurvy  and  has  the  advantage  of  being  inexpensive 
since  the  orange  itself  may  be  used  for  other  purposes. 

But  orange  juice  and  lemon  juice  are  generally  accepted  as 
being  the  most  valuable  of  all  anti-scorbutics.  Orange  juice 
may  be  started  early,  and  to  be  of  value  as  a  preventive,  must 
be  started  early  or  scurvy  will  have  started  to  develop.  The 
common  practice  is  to  give  a  dram,  daily,  at  three  months,  in- 
crease it  to  an  ounce  by  the  sixth  month  and  two  ounces  when 
the  baby  is  a  year  old.  It  should  be  diluted  with  water  and 
given  in  two  doses,  midway  between  two  morning  and  afternoon 
feedings. 

To  sum  up :  Scurvy  in  infants  or  adults  is  the  result  of  a  diet 
which  is  deficient  or  lacking  in  the  anti-scorbutic  substance, 
called  water-soluble  C,  and  may  be  prevented  or  cured  by  adding 
to  the  faulty  diet  those  articles  of  food  which  contain  this  sub- 
stance, namely,  fresh  milk,  oranges,  leafy,  green  vegetables,  cab- 
bage, onions,  potatoes  or  tomatoes.  Although  scurvy  is  seldom 
seen  in  breast-fed  babies  it  is  believed  that  an  infant  nursing 
at  the  breast  of  a  woman  whose  diet  is  poor  or  lacking  in  the  anti- 
scorbutic substance  may  suffer  a  certain  degree  of  starvation  for 
this  food  factor. 

Recent  work  at  the  University  of  Minnesota  has  shown  that 
milk  from  cows  on  dry  feeds  is  very  much  lower  in  anti-seorbutie 
properties  than  milk  from  cows  on  green  pasture.  This  provides 
a  strong  argument  for  giving  orange  juice  to  all  artificially  fed 
babies,  for  one  cannot  always  know  how  the  cows,  from  which 
the  milk  is  obtained,  are  fed. 

Beri-beri  is  a  deficiency   disease,   chiefly  characterized  by 


NUTRITION  OF  THE  MOTHER  AND  HER  BABY    377 

paralysis  and  caused  by  a  diet  which  is  lacking  or  poor  in  water- 
soluble  B.  The  foods  which  entirely  lack  this  substance  are 
polished  rice,  starch,  sugar,  glucose,  and  the  fats  and  oils  from 
both  animal  and  vegetable  sources,  while  those  which  are  poor 
in  it  are  the  products  of  degerminated  cereal  grains,  such  as 
tapioca,  hominy,  cornmeal,  macaroni,  spaghetti  and  the  muscle 
cuts  of  meat,  such  as  steak,  roast,  chops,  ham  and  fish  and  fowl 
muscle.  Foods  which  are  rich  in  water-soluble  B  are  beans,  peas, 
the  root  vegetables  as  beets,  carrots,  white  and  sweet  potatoes, 
leafy  vegetables,  fruits,  milks,  eggs  and  the  glandular  organs 
such  as  liver,  kidneys  and  sweet  breads. 

The  early  symptoms  of  beri-beri  are  fatigue  and  depression ; 
numbness  and  stiffness  in  the  legs;  more  or  less  edema  of  the 
ankles  and  face,  followed  by  tenderness  of  the  calf  muscles,  and 
tingling  or  burning  sensations  in  the  feet,  legs  and  arms.  There 
are  two  types  of  the  disease,  the  dry  and  the  wet.  In  the  dry 
tj'^pe,  wasting  anesthesia  and  paralysis  are  the  chief  symptoms, 
while  the  most  marked  evidences  of  the  wet  type  are  the  edema, 
which  may  be  excessive,  affecting  the  entire  body.  The  death 
rate  from  beri-beri  is  usually  high. 

We  are  accustomed  to  thinking  of  this  disease  as  occurring 
chiefly  among  the  Orientals,  for  it  was  long  confined  to  Southern 
China,  Japan,  the  Dutch  East  Indies  and  the  Malay  Peninsula. 
But  it  may  occur  among  any  people  whose  diet  is  poor  in  those 
foods  containing  the  particular  substance  which  protects  against 
it.  It  is  common  in  Newfoundland  and  Labrador  and  certain 
parts  of  South  America  and  among  people  who  eat  little  aside 
from  staple,  non-perishable,  cereal  products,  wheat  bread  made 
from  bolted  flour,  fish  and  salt  meats.  An  evidence  of  this  near 
at  home  was  an  outbreak  of  typical  beri-beri,  in  the  jail  at  Eliza- 
beth, N.  J.,  in  1914,  caused  by  the  faulty  diet  of  the  inmates. 

The  disease  may  be  prevented  or  cured  only  by  including  in 
the  diet  such  food  as  milk,  eggs,  fresh  fruit  and  vegetables. 

Xerophthalmia  is  a  deficiency  disease  characterized  by  eye 
lesions  and  due  to  a  lack  of,  or  deficiency  in  the  diet  of  the  pro- 
tective substance  which  has  been  designated  as  fat-soluble  A. 
This  substance  is  absent  in  polished  rice,  and  present  in  but  small 
amounts  in  barley  and  other  cereals ;  in  muscle  cuts  of  meat ;  in 


378  OBSTETRICAL  NURSING 

peas,  beans  and  other  vegetables  excepting  those  described  as 
"leafy."  It  is  contained  in  cod-liver  oil,  butter,  cream,  egg 
yolk,  liver,  kidneys  and  the  leafy  vegetables. 

In  the  early  stages  of  the  disease  the  eyes  are  inflamed  and 
the  lids  badly  swollen.  If  the  diet  is  wholly  lacking  in  fat- 
soluble  A,  the  disease  progresses  rapidly,  the  eye  balls  frequently 


HBhC-V 

^^V1 

II 

i'H.fll 

'^•esi^Mli^.         a^B 

^^- 

;tf%  ■ 

P^^^tt^^ 

Fig.  140. — This  baby  is  totally  blind  in  the  left  eye  as  a  result  of 
ulcers,  due  to  a  long  continued  diet  of  cereals  with  a  little  skimmed  milk; 
in  other  words,  a  diet  poor  in  fat-soluble  A.  The  right  eye  became  in- 
volved but  administration  of  cod-liver  oil  was  followed  by  speedy  recovery 
and  partial  vision  was  saved.  There  is  little  doubt  but  that  the  baby 
would  have  been  totally  blind  had  the  faulty  diet  been  continued.  (From 
the  Newer  Knowledge  of  Nutrition,  by  E.  V.  McCoUum.) 


rupture  and  the  lens  and  vitreous  humor  are  expelled,  with 
total  and  permanent  blindness  as  the  tragic  result.  On  the  other 
hand,  the  malady  clears  up  in  a  very  spectacular  manner  if,  in 
the  early  stages,  the  patient  is  fed  those  foods  which  contain 
the  mysterious,  but  indispensable  fat-soluble  A. 

Well  developed  xerophthalmia  is  not  common  in  this  country 


NUTRITION  OF  THE  MOTHER  AND  HER  BABY  379 

but  one  sees  inflamed  eyes  and  corneal  ulcers  in  young  chil- 
dren which  clear  up  with  little  local  treatment  after  a  mother 
has  been  persuaded  to  give  the  patient  more  fresh  milk,  butter 
and  green  vegetables. 

Mori  reports  upon  about  1500  cases  occurring  in  Japan,  in 
1905,  among  children  between  the  ages  of  two  and  five  years. 
He  states  that  the  disease  does  not  occur  among  the  fisher  folk 
but  among  people  whose  diet  is  largely  composed  of  rice,  barley, 
cereals,  beans  and  "other  vegetables,"  but  he  does  not  state 
what  the  other  vegetables  are.  Prompt  relief  of  the  eye  symp- 
toms was  observed  when  cod-liver  oil,  chicken  livers  and  eel  fat 
were  administered. 

Bloch  describes  cases  of  xerophthalmia  among  infants  under 
one  year  of  age,  in  the  vicinity  of  Copenhagen,  during  the  years 
of  1912  and  1916.  (Fig.  140.)  The  babies  were  also  suffering 
from  malnutrition  and  the  skin  was  dry,  shrivelled  and  scaly. 
Their  diet  consisted  largely  of  separator  skimmed  milk,  which 
was,  therefore,  practically  fat-free,  oatmeal  gruel  and  barley 
soup.  The  milk  was  pasteurized  and  then  cooked  in  the  home 
before  being  fed  to  the  babies.  Such  i.  diet  was  so  faulty  that 
the  infants  in  question  may  well  have  been  border-line  cases  of 
scurvy  and  beri-beri,  as  well  as  developed  cases  of  xerophthalmia. 
It  is  also  evident  that  the  children  were  unquestionably  suffer- 
ing from  rickets. 

It  is  believed  that  the  condition  known  as  night-blindness  is 
related  to,  or  a  mild  or  early  form  of  xerophthalmia.  It  occurs 
in  Newfoundland  and  Labrador,  among  men  in  lumber 
camps  and  elsewhere,  whose  diet  consists  chiefly  of  wheat  flour, 
beans,  meat,  fish,  molasses,  raisins  and  coffee.  Such  a  diet  is 
made  up  of  those  parts  of  the  plant  or  animal  which  have  good 
keeping  qualities,  but  these  qualities  do  not  compensate  for  the 
poverty  of  the  protective  substance. 

Dr.  Anna  Strong,  who  has  had  experience  as  a  medical  mis- 
sionary in  India,  observes  that  night-blindness  is  common  in  the 
vicinity  of  Calcutta,  and  it  is  said  to  occur  frequently  in  Russia 
during  the  Lenten  fasts.  The  popular  treatment  for  this  con- 
dition consists  of  poulticing  the  eyes  with  fresh  goat 's  liver  and 
giving  the  liver  as  a  food  as  well;  while  in  Japan  the  efficacy 


380  OBSTETRICAL  NURSING 

of  eating  liver  to  cure  night-blindness  lias  been  recognized  from 
early  times. 

Pellagra  is  a  disease  of  obscure  origin,  associated  with  faulty 
nutrition,  which  involves  the  nervous  and  digestive  systems  and 
the  skin.  Usually  one  of  the  first  symptoms  is  soreness  and  in- 
flammation of  the  mouth,  then  a  remarkable,  symmetrical  erup- 
tion appears  on  parts  of  the  body,  which,  with  weakness,  nerv- 
ousness and  indigestion  form  the  most  characteristic  picture  of 
the  disease. 

There  are  some  indications  that  infection  may  be  the  imme- 
diate cause,  but  the  strong  evidence  is  that  a  faulty  diet  is  the 
chief  predisposing  cause  of  the  disease.  Certain  it  is  that 
pellagra  is  both  prevented  and  cured  by  a  diet  containing  liberal 
amounts  of  milk,  eggs  and  leafy  vegetables.  On  the  other  hand, 
those  who  live  during  the  winter  months  on  a  diet  chiefly  de- 
rived from  bolted  white  flour,  degerminated  cornmeal,  polished 
rice,  starch,  sugar,  molasses  and  fat  pork,  furnish  the  victims 
of  this  dreaded  disease  in  the  spring. 

Pellagra  was  discovered  in  Northern  Spain,  by  Cassal,  in 
1735,  but  for  many  years  it  had  been  of  common  occurrence 
in  parts  of  Italy,  and  during  the  last  century  has  been  prevalent 
in  parts  of  France,  the  Balkans,  especially  Roumania,  and  for 
a  lesser  time,  in  Egypt.  In  America  the  disease  was  not  recog- 
nized with  certainty  until  1908,  but  from  that  year  its  incidence 
apparently  increased,  until  by  1917  there  were  170,000  cases  of 
pellagra  recorded  in  the  United  States,  principally  located  in 
the  Southern  States. 

In  1914,  Dr.  Joseph  Goldberger,  of  the  United  States  Public 
Health  Service,  began  an  investigation  of  the  factors  concerned . 
in  causing  pellagra.  After  he  had  studied  its  prevalence  in  vari- 
ous orphanages  in  the  South,  and  had  relieved  the  situation  by 
improving  the  diet  with  milk,  fresh  vegetables  and  meat,  he  was 
anxious  to  know  whether  the  disease  could  be  produced  by^  a 
faulty  dietary,  of  the  type  common  among  pellagrins.  He 
planned  an  experiment  to  this  end,  which  would  restrict  men  to 
a  diet  similar  to  that  which  had  been  supplied  in  the  institutions 
where  pellagra  had  been  endemic,  and  where  it  had  been  relieved 
by  the  improvements  in  the  food  supply  which  have  been  men- 


NUTRITION  OF  THE  MOTHER  AND  HER  BABY  381 

tioned.  This  type  of  diet  was  also  very  characteristic  of  that  used 
in  the  homes  of  the  cotton  mill  workers  throughout  the  South, 
where  pellagra  was  so  common.  The  Governor  of  Mississippi 
offered  pardon  to  any  of  the  healthy  white  men  in  the  state  prison 
who  would  submit  themselves  as  subjects  for  the  experiment,  and 
eleven  actually  underwent  the  test. 

The  men  were  put  upon  a  diet  consisting  of  articles  made 
from  white,  wheat  flour,  degerminated  cornmeal  (maize),  pol- 
ished rice,  starch,  sugar,  molasses,  pork  fat,  sweet  potatoes,  coffee 
and  very  small  quantities  of  collards  and  turnip  greens — so  small 


Fig.  141. — Eachitic  baby  and  normal  baby  of  the  same  age,  showing 
dwarfism  and  deformities  caused  by  rickets.  (By  courtesy  of  Dr.  Leonard 
Findlay,  Glasgow,  Scotland.) 

as  to  furnish  inadequate  protection  against  a  certain  degree  of 
undernourishment.  At  the  end  of  five  and  a  half  months  six  of 
the  eleven  men  developed  the  skin  lesions  characteristic  of  in- 
cipient pellagra. 

As  a  result  of  his  investigations.  Dr.  Goldberger  points  out 
the  important  fact  that  when  milk,  eggs,  meat,  fresh  fruit  and 
vegetables  are  included  in  the  diet,  pellagra  does  not  develop,  also 
that  the  disease  may  be  cured  by  giving  these  articles  of  food  to 
the  afflicted  person. 

Rickets.     The  actual  cause  of  rickets  is  not  definitely  known, 


382  OBSTETRICAL  NURSING 

but  the  disease  apparently  results  from  wrong  proportions  be- 
tween calcium  and  phosphorus,  and  to  unfavorable  amounts  of 
these  two  substances  in  the  food.  Accordingly,  it  may  be  said 
to  be  due  to  a  faulty  diet — one  which  is  rich  in  carbohydrates 
and  poor  in  fats  and  possibly  some  substance  as  yet  unrecognized 
— and  it  may  be  both  prevented  and  cured  by  what  is  now  re- 
garded as  suitable  feeding. 

The  chief  characteristics  of  the  disease  are  arrested  growth 
and  softening  of  the  bones,  with  dwarfism  and  deformities  as  a 
result.  (Fig,  141.)  It  is  essentially  a  disease  of  infancy,  oc- 
curring as  a  rule,  between  the  fourth  and  eighteenth  months  but 
some  of  its  unfavorable  effects,  such  as  bone  deformities  and 
poor  resistance  to  disease,  may  persist  throughout  life. 

Although  babies  rarely  die  of  rickets  alone,  it  is  one  of  the 
most  serious  of  all  health  problems  and  obstacles  to  normal  de- 
velopment and  stability,  since  it  predisposes  to  such  diseases  as 
bronchitis,  pneumonia,  tuberculosis,  measles,  and  whooping 
cough  and  in  general  greatly  enfeebles  the  powers  of  resistance 
and  recuperation. 

It  is  common  among  babies  who  are  fed  solely  or  continu- 
ously on  heated  milk,  either  boiled  or  canned,  and  on  proprietary 
foods  and  sweetened  condensed  milk.  There  has  been  some 
speculation  about  the  possible  relation  between  rickets  and  fat- 
soluble  A,  but  no  definite  conclusions  have  yet  been  reached. 
It  is  known,  however,  that  rickets  may  develop  among  nursing 
babies  whose  mothers  are  on  faulty  diets,  and  that  the  disease 
may  be  prevented  and  cured  by  the  administration  of  cod-liver 
oil,  which  is  rich  in  fat-soluble  A.  Sunshine,  also,  seems  to  have 
a  pronounced  effect  in  preventing  and  in  curing  the  disease. 

Symptoms.  The  common  symptoms  of  rickets  which  appear 
early  are  irritability;  restlessness  particularly  at  night;  a  ten- 
dency toward  convulsions  from  very  slight  cause;  digestive  dis- 
turbances and  profuse  perspiration  about  the  head.  The  baby 
may  be  fat,  but  is  likely  to  be  flabby  and  to  have  a  characteris- 
tically white,  "pasty"  color.  The  fontanelles  are  large  and  late 
in  closing ;  the  abdomen  is  large  and  the  chest  narrow ;  dentition 
is  usually  delayed  and  the  teeth  may  be  soft  and  decay  early. 
But  the  most  conspicuous  effect  of  rickets  is  upon  the  entire  bony 


NUTRITION  OF  THE  MOTHER  AND  HER  BABY    383 

skeleton,  due  to  the  inadequacy  of  the  lime  deposit.  The  bones 
are  soft,  easily  bent  and  broken  and  often  misshapen.  Their 
growth  is  likely  to  be  retarded  and  the  ends  of  the  long  bones 
may  be  enlarged,  giving  the  familiar  rwollen  wrists  and  ankles, 
while  the  nodules  which  form  at  the  junction  of  the  ribs  and 


Fig.  142. — Exterior  of  thorax  of  normal  rat  and  rachitic  rat  of  same 
age.  The  latter  shows  dwarfism  and  deformities  resembling  pigeon  breast 
so  frequently  seen  in  human  beings  suffering  from  rickets.  (From  The 
Newer  Knowledge  of  Nutrition,  by  E.  V.  McCollum.) 

sternum,  produce  the  beaded  appearance  so  commonly  called  a 
"rickety  rosary."  The  bones  in  the  arms  and  legs  may  become 
curved  as  the  baby  lies  or  sits  in  its  crib,  making  him  either  bow- 
legged  or  knock-kneed.  The  deformity  is  increased  by  walking 
because  the  soft  bones  are  easily  bent  by  the  weight  of  the  body. 
The  spinal  column  may  be  curved  or  too  weak  to  permit  the  baby 
to  sit  straight  or  stand  alone.     The  entire  chest  wall  is  often 


384  OBSTETRICAL  NURSING 

deformed  (Figs.  142,  143)  producing  the  familiar  "chicken 
breast,"  as  well  as  a  serious  decrease  in  the  size  of  the  thoracic 
cavity,  and  through  loss  of  rigidity  of  the  bony  wall,  the  respira- 
tory movements  may  be  seriously  impaired.  The  forehead  is 
prominent  and  the  whole  head  looks  square  and  larger  than 
normal,  while  the  pelvic  deformities  in  girl  babies  often  give 
rise  to  very  serious  obstetrical  complications  later  in  life,  as  has 
been  previously  explained. 

Although  lack  of  fresh  air  and  sunshine  seem  to  be  factors 
in  producing  rickets,  it  has  been  observed  that  the  disease  does 


/ 


(* 


AttacfiWent      ..-' 
of  Diaphragm*, 


^\.---     .:•  1 


Fig.  143. — Interior  of  specimens  in  Fig.  142  showing  nodules,  due  to 
rickets,  protruding  into  thoracic  cavity  and  encroaching  upon  space  occu- 
pied by  heart  and  lungs.  This  is  a  factor  in  the  respiratory  diseases  which 
frequently  complicate  rickets. 

not  develop  in  poor  surroundings  if  the  diet  is  suitable  or  if 
cod-liver  oil  is  given  to  babies  fed  artificially,  or  on  unsatisfac- 
tory breast  milk ;  but  that  it  may  occur  in  the  presence  of  satis- 
factory hygienic  conditions  if  the  diet  is  faulty  in  certain  re- 
spects. For  children  under  a  year  old,  the  desirable  food  is 
good  breast  milk,  or,  lacking  that,  fresh,  certified  cows'  milk, 
with  fruit  juices,  scraped  beef,  eggs  and  strained  vegetable 
purees,  started  as  early  and  increased  as  rapidly  as  the  baby 
can  digest  them. 


NUTRITION  OF  THE  MOTHER  AND  HER  BABY    385 

Treatment.  Cod-liver  oil  and  sunshine,  together  with  proper 
food,  are  the  essentials  in  treating  rickets.  When  cod-liver  oil 
is  given  to  a  baby  whose  diet  is  faulty,  it  exerts  a  marked  ten- 
dency toward  enabling  the  bones  to  develop  satisfactorily  even 
when  the  mineral  content  of  the  food  is  unfavorable.  The  use 
of  sunshine,  either  by  moving  the  baby  from  a  dark  to  a  light 
house,  or  by  exposing  his  body  to  the  direct  rays  of  the  sun  is 
found  to  be  of  pronounced  therapeutic  value.  These  factors, 
in  addition  to  general  good  care  constitute  the  treatment,  but 
it  is  a  long  slow  process,  taking  from  three  to  fifteen  months, 
and  it  is  doubtful  if  the  damage  which  the  disease  works  can 
ever  be  entirely  repaired. 

Rickets  is  more  common  during  the  cold  months  of  the  year, 
winter  and  spring,  than  during  the  milder  summer  and  autumn 
seasons.  A  possible  explanation  for  this  lies  in  the  higher  value 
of  the  cows'  food  during  the  warm  months  when  green  things 
form  the  diets  of  animals.  Since  it  is  now  recognized  that  milk 
is  not  a  constant  product,  but  that  its  properties  vary  with  the 
food  of  the  animals  that  produce  it,  cows'  milk  would  be  favor- 
ably influenced  by  their  being  put  to  pasture. 

Similar  evidence  of  such  an  influence  is  seen  in  the  fact  that 
although  rickets  is  not  seen  among  breast-fed  babies  whose 
mothers  are  on  satisfactory  diets,  it  may  and  does  occur  in 
breast-fed  babies  who  are  nourished  by  mothers  who  are,  them- 
selves, on  dietaries  which  are  poor  in  milk  and  fresh  fruit  and 
vegetables. 

Drs.  Hess  and  Unger  made  a  study  of  the  occurrence  of 
rickets  among  colored  babies  in  a  section  of  New  York  City  and 
the  value  of  cod-liver  oil  as  a  preventive  of  this  disease.  In  com- 
menting upon  their  findings,  they  state,  "This  tendency  is  so 
marked  that  it  may  be  safely  stated  that  over  ninety  per  cent, 
of  the  colored  babies  have  rickets,  and  that  even  a  majority  of 
those  that  are  breast-fed  show  some  signs  of  this  disorder." 
They  ascertained  that  the  average  diet  of  the  mothers  of  these 
rickety  babies  was  largely  made  up  of  carbohydrates  and  pro- 
teins, being  poor  in  fats,  although  the  diets  yielded  a  daily  quota 
of  calories  which  represented  almost  the  requisite  amount  for 


386  OBSTETRICAL  NURSING 

their  individual  weights.  But  they  took  little  fresh  milk  or 
fresh  fruit  or  vegetables,  using  canned  and  dried  products  freely. 

It  is  important  to  note  here  that  it  is  a  diet  of  heated  milk, 
rich  in  carbohydrates  but  poor  in  fats,  that  produces  rickets  in 
a  bottle-fed  baby — almost  the  same  type  of  diet  which  in  a 
nursing  mother  results  in  rickets  in  a  breast-fed  baby. 

In  an  endeavor  to  prevent  rickets  among  these  incompletely 
nourished  babies,  Drs.  Hess  and  Unger  carried  on  a  definitely 
organized  experiment.  "Our  plan,"  they  report,  "was  to  give 
infants  under  six  months  one-half  teaspoonful  of  oil  three  times 
daily  and  older  infants  twice  this  amount.  It  was  found  that 
almost  all  babies  can  take  cod-liver  oil,  although  it  may  disagree 
temporarily  and  may  have  to  be  discontinued  for  short  intervals 
when  there  is  digestive  disturbance.  Infants  of  from  two  to 
three  months  tolerate  the  oil  in  half-teaspoonful  doses,  and 
younger  ones  may  be  given  still  smaller  amounts."  In  com- 
menting upon  the  tabulated  results  of  this  interesting  study  they 
say:  "It  is  seen  that  we  were  able  to  prevent  the  development 
of  rickets  in  more  than  four-fifths  of  the  infants  who  received 
the  oil  for  six  months,  and  in  more  than  half  of  those  who  were 
given  it  for  four  months.  This  result  must  be  considered  satis- 
factory when  we  note  that,  of  the  sixteen  infants  who  did  not 
receive  the  oil,  fifteen  showed  signs  of  rickets,  though  all  of  them 
lived  under  the  same  conditions  and  many  in  the  very  same 
families.  No  other  treatment  was  given,  nor  was  a  change  of 
diet  or  mode  of  life  attempted  which  could  account  for  the  dif- 
ference in  the  results  between  the  two  groups  of  cases."  The 
poor  quality  of  the  breast  milk  of  these  inadequately  nourished 
mothers  is  suggested  by  the  further  statement:  "Table  two 
shows  that  the  cod-liver  oil  proved  to  be  a  more  potent  factor  than 
breast  feeding  in  warding  oif  rickets,  and  that  almost  all  the 
colored  babies  developed  rickets  even  though  nursed." 

It  may  seem  like  a  far  cry  from  scurvy  among  sailors,  on 
shipboard,  xerophthalmia  among  lumbermen  in  Labrador,  and 
beri-beri  among  the  Orientals  to  the  nursing  mother  and  her 
baby  in  our  care. 

But  when  we  gather  all  of  these  apparently  unrelated  threads 
together  and  consider  them  in  their  possible  relation  to  this  same 


NUTRITION  OF  THE  MOTHER  AND  HER  BABY    387 

nursing  mother  and  her  baby,  right  here  at  hand,  the  following 
facts  stand  ont  as  being  of  insistent  importance  to  their  well- 
being  : 

1.  There  are  five  recognized  diseases  resulting  from  faulty  nutri- 
tion, which  may  be  both  prevented  and  cured  by  a  diet  which 
contains  the  protective  substances  which  are  now  regarded  as 
essential  to  normal  growth,  development  and  well-being. 

2.  These  essential  substances  are  not  necessarily  provided  in  ade- 
quate amounts  by  a  diet  that  is  satisfactory  in  bulk  or  in  its 
balance  of  fats,  carbohydrates,  proteins,  salts  and  water  or  that 
yields  the  requisite  number  of  calories.  The  familiar  diet  of 
meat,  potatoes,  peas,  beans,  bread,  pie  and  coffee  is  so  far  from 
providing  complete  nourishment  that  those  who  are  limited  to 
it  are  in  a  state  of  partial  starvation, 

3.  The  diseases  resulting  from  a  lack  or  deficiency  of  the  protective 
substances,  fat-soluble  A,  water-soluble  B  and  water-soluble  C, 
respectively,  are  xerophthalmia,  beri-beri  and  scurvy.  With 
these  are  often  included  pellagra  and  rickets,  the  causes  of  which 
are  not  definitely  known  but  result  from  diets  that  are  poor  in 
certain  respects.  The  serious  aspect  of  the  deficiency  diseases, 
however,  does  not  lie  entirely  in  those  conditions  which  are  well 
enough  developed  to  be  recognizable,  thus  prompting  treatment; 
but  also  in  the  wide  prevalence  of  malnutrition,  of  some  form, 
which  is  not  severe  enough  to  be  diagnosed  as  disease,  and 
which  is  caused  by  a  sustained  diet  that  is  poor  in  one  or  more 
essential  food  factors.  This  condition  is  serious  because  it  pro- 
duces a  legion  of  individuals  who  are  spoken  of  as  being  "not 
strong."  They  are  tired,  nervous,  susceptible  to  infections,  have 
poor  recuperative  powers  and  in  general  fall  short  of  a  normal 
state  of  health  and  efficiency. 

4.  Although  the  breast  tissues  are  capable  of  converting  into  milk 
certain  substances  which  they  extract  from  the  blood,  and  may, 
for  example,  convert  poor  proteins  into  proteins  of  higher 
value,  they  cannot  create  the  protective  substances  which  we 
have  been  considering.  They  can  merely  excrete  these  substances 
if  they  are  contained  in  the  mother's  diet.  The  absence,  or 
shortage  of  these  food  essentials  in  the  mother's  diet,  and  there- 
fore in  her  milk,  may  result  in  rickets  or  other  malnourished 
conditions  in  the  baby,  or  in  a  degree  of  faulty  nutrition  which 
is  not  marked  enough  to  be  diagnosed,  but  enough  to  keep 
him  frail.  Enough  to  give  him  the  poor  start  that  is  so  likely 
to  put  him,  ultimately,  in  the  class  of  those  adults  who  are  more 
or  less  unfit,  though  not  actually  ill. 

We  must  see  to  it,  therefore,  that  our  selection  of  food  for 


388  OBSTETRICAL  NURSING 

the  expectant  and  nursing  mother  provides  those  substances 
which  are  necessary  to  promote  growth  and  development  and 
preserve  health,  if  we  are  to  live  up  to  our  claim  that  the  aim 
of  obstetrical  nursing  is  to  aid  in  building  a  strong,  vigorous  and 
buoyant  race. 

The  nurse  may  find  herself  feeling  a  bit  dismayed  at  the  pros- 
pect of  trying  to  remember  at  all  times  which  foods  contain  fat- 
soluble  A,  for  example,  and  which  are  poor  in  water-soluble  C, 
but  she  can  remember  in  general,  that  milk  and  leafy  vegetables 
are  the  great  protective  foods  and  that  any  diet  which  is  poor  in 
these  is  incapable  of  nourishing  satisfactorily ;  and  by  calling  to 
mind  the  deficiency  diseases,  previously  described,  she  will  be 
impressed  anew  by  the  seriousness  of  faulty  nutrition. 

By  milk  we  mean,  in  addition  to  fresh  milk,  cream,  butter, 
butter-milk,  cream-soups  and  sauces,  custards,  ice-cream  and  all 
dishes  and  beverages  made  of  milk. 

By  leafy  vegetables  we  mean  lettuce,  romaine,  endive,  cress, 
celery,  cabbage,  spinach,  onions,  string  beans,  asparagus,  cauli- 
flower, Brussels  sprouts,  artichokes,  beet  greens,  dandelions, 
turnip  tops  and  the  like. 

Other  foods  which  are  rich  in  protective  substances  are  fresh 
fruit,  egg-yolks  and  glandular  organs. 

Nearly  all  of  the  common  foods  are  deficient  in  some  respect, 
but  as  the  shortcomings  of  the  various  groups  are  different,  we 
can  arrange  entirely  satisfactory  diets  by  combining  foods  which 
supplement  each  other's  deficiencies.  This  explains  to  us  why 
the  meat-potato-peas-beans-bread-and-pie  type  of  meals  fails  to 
supply  adequate  nourishment.  These  foods  belong  in  the  same 
general  group  and  are  deficient  in  about  the  same  kind  of  food 
factors,  thus  tending  to  duplicate,  rather  than  supplement  each 
other. 

If  such  a  fare  is  enriched  by  the  addition  of  the  protective 
foods,  milk  and  leafy  vegetables,  we  have  a  well  rounded  diet 
in  which  the  deficiencies  of  one  group  of  foods  are  supplied  by 
the  properties  of  the  other  groups.  In  fact,  it  is  only  by  such 
a  supplementing  combination  that  an  entirely  satisfactory  diet 
can  be  secured. 

Dr.  McCollum  points  out  that  the  mother  on  a  faulty  diet 


NUTRITION  OF  THE  MOTHER  AND  HER  BABY  389 

cannot  nurse  her  baby  to  his  advantage.  * '  The  mammary  gland,'* 
he  says,  "picks  up  from  the  blood  both  of  the  chemically  un- 
identified food  essentials,  fat-soluble  A  and  water-soluble  B,  and 
passes  these  into  the  milk,  but  it  is  unable  to  produce  either  of 
these  substances  anew.  When  one  or  the  other  of  these  is  absent 
from  the  mother's  diet  it  is  not  found  in  the  milk.  We  have 
shown  the  possibility  of  producing  milk,  poor  or  lacking  in  each 
of  these  substances  and  therefore  not  capable  of  inducing 
growth. ' '  ^ 

Dr.  W.  E.  Musgrave  gives  dramatic  accounts  of  the  effect 
upon  nursing  babies  of  faulty  nutrition  among  mothers  in  the 
Philippines,  as  follows:  "Infant  mortality  in  Manila,"  he 
writes,  "is  greater  than  it  is  in  any  other  city  from  which  we 
have  records.  The  underdeveloped  and  undernourished  condi- 
tion of  the  great  masses  of  the  Filipino  people  is  due  to  a  num- 
ber of  causes,  the  principal  one  being  insufficient  quantity  and 
injudicious  variety  of  foodstuffs  employed.  The  cause  of  the 
enormous  influence  of  the  faulty  nutrition  of  the  mothers  upon 
infant  mortality  directly  and  indirectly  is  one  of  the  most  im- 
portant subjects  within  the  scope  of  any  investigation  of  this 
character.  The  mortality  in  breast-fed  children  is  higher  than 
it  is  among  children  artificially  fed.  This  condition  so  far  as 
we  know  is  peculiar  to  the  Philippines.  The  logical,  and  we 
believe,  the  correct  explanation  of  this  is  the  deficiency  in  quality 
and  quantity  of  the  mother's  milk.  There  are  not  in  history 
more  pathetic  examples  of  unavailing  self-sacrifice  than  are  daily 
seen  in  our  large  clinics  of  poor,  half-starved,  undernourished 
mothers  attempting  to  supply  from  their  breasts  food  enough 
for  one  or  more  children,  when  their  own  metabolisms  are  in  a 
starved  condition.  When  asked  the  direct  question  as  to  the 
supply  of  foodstuffs  these  mothers  almost  invariably  state  that 
they  have  plenty  to  eat  and  the  pathetic  part  of  the  story  is 
that  they  believe  that  they  are  stating  facts.  These  abnormal 
premises  are  the  result  of  a  peculiar  unexplainable  psychology 
that  is  of  very  wide  application  in  this  country  that  the  ad- 

*"The  Nursing  Mother  as  a  Factor  of  Safety  in  the  Nutrition  of  the 
Young."  E.  V.  McCollum  and  N.  Sinimonds,  The  American  Journal  of 
Physiology,  June,  1918. 


390  OBSTETRICAL  NURSING 

ministration  of  food  is  more  to  satisfy  hunger  than  to  produce 
flesh  and  blood,  and  that  the  cheapest  way  in  which  hunger 
may  be  satisfied  produces  a  satisfactory  form   of   existence." 

It  is  generally  agreed  that  the  two  big  problems  of  babyhood 
are  proper  nutrition  and  the  prevention  of  infection,  but  nutri- 
tion is  perhaps  the  greater  problem,  since  any  form  or  degree 
of  malnutrition  lessens  the  baby 's  powers  to  resist  and  to  recover 
from  infection.  Whether  breast-fed  or  bottle-fed,  therefore,  it 
is  imperative  that  the  baby  be  nourished  in  the  complete  sense 
of  being  given  all  of  the  food  materials  which  are  essential  to 
normal  growth,  development  and  protection  against  disease. 

If  the  baby  is  artificially  fed  on  milk  that  has  been  heated, 
his  diet  needs  to  be  augmented  by  such  protectives  as  cod-liver 
oil  and  orange  juice,  since  the  protective  properties  of  milk  are 
impaired  by  heating.  If  he  is  breast-fed,  the  mother  will  be 
able  to  supply  to  her  baby  the  requisite  nourishment  and  pro- 
tective substances  only  if  she,  herself,  is  adequately  nourished 
and  in  good  condition. 

That  is  the  point  of  this  entire  discussion:  The  nursing 
mother  must  be  on  a  satisfactory  diet  or  she  cannot  satisfac- 
torily nurse  her  baby.  And  by  satisfactorily  nursing  her  baby 
we  mean,  to  give  him  from  the  beginning,  through  her  milk,  the 
materials  necessary  to  build  well  and  firmly  that  temple,  in  the 
shape  of  his  body,  which  he  will  occupy  throughout  life ;  a  struc- 
ture so  securely  built,  from  the  foundation  up  through  each 
stage,  that  it  will  be  able  to  withstand  the  attacks  of  disease  and 
weather  the  inevitable  storm  and  stress  of  life. 

BIBLIOGRAPHY 

McCoUum.     The  Newer  Knowledge  of  Nutrition,   2nd  edition.     New 

York,  1918. 
MeCollum  and  Simmonds.     The  American  Home  Diet,  Detroit,  1919. 
McCollum.     Newer  Aspects  of  Nutrition,  Proceedings  of  the  Institute 

of  Medicine  of  Chicago,  1920,  iii,  13. 
Musgrave,  W.  E.     The  Philippine  Jour,  of  Science,  Series  B,  vol.  8, 

1913,  459. 
Goldberger,  J.     Jour.  Amer.  Med.  Assoc,  1916,  Ixvi,  471. 
Hess,  A.  F.  and  Unger,  L.  J.     Prophylactic  Therapy  for  Rickets  in  a 

Negro  Community. 


CHAPTER  XVIII 
COMPLICATIONS  OF  THE  PUERPERIUM 

The  most  important  of  the  complications  of  the  puerperium 
are  subinvolution  and  malpositions  of  the  uterus;  breast 
abscesses;  hemorrhage  and  infection. 

The  importance  of  these  to  the  nurse  lies  in  their  prevent- 
ability,  by  means  of  the  clean  and  efficient  care  which  she  helps 
to  give  during  pregnancy,  labor  and  the  early  weeks  after  the 
baby  is  born. 

The  nurse's  part  in  prevention  and  treatment  of  subinvolu- 
tion, malpositions  of  the  uterus  and  breast  abscesses  is  so  bound 
up  in  the  daily  care  of  the  young  mother  that  it  was  described 
in  the  preceding  chapter. 

Hemorrhage.  Under  ordinary  conditions,  a  patient  may  lose 
as  much  as  500  cubic  centimetres  of  blood  during  or  immediately 
after  labor,  without  serious  results,  but  a  loss  of  600  cubic  centi- 
metres or  more  is  regarded  as  a  hemorrhage  and  as  requiring 
speedy  attention. 

According  to  Dr.  Williams,  severe  hemorrhage  occurs  only 
once  in  every  few  hundred  labors,  and  with  proper  treatment, 
should  not  result  fatally  in  more  than  one  out  of  every  2000  or 
2500  cases. 

The  severe  hemorrhage  due  to  a  partially  separated  placenta 
occurs  during  the  third  stage  of  labor  and  was  discussed  in  that 
connection.  As  the  danger  of  hemorrhage,  after  labor  is  com- 
pleted, is  greatest  during  that  critical  hour  immediately  follow- 
ing, it  is  practically  routine  the  country  over  to  watch  the  pa- 
tient closely  during  this  period,  both  for  the  sake  of  preventing 
bleeding  and  detecting  its  early  evidence,  should  hemorrhage 
occur,  thus  making  prompt  treatment  possible. 

The  causes  of  post-partum  hemorrhage  are :  Deep  cervical 
tears,  retained  portions  of  the  placenta,  and  atony  of  the  uterus. 

391 


392  OBSTETRICAL  NURSING 

The  treatment  of  hemorrhage  due  to  tears  of  the  generative 
tract  is  suturing  the  torn  edges. 

Since  the  retention  of  even  a  small  piece  of  placental  tissue 
will  prevent  the  uterus  from  contracting  firmly,  the  treatment 
of  hemorrhage  from  this  cause  is  immediate  removal  of  the 
retained  fragment.  It  is  to  obviate  this  occurrence  that  the 
placenta  is  carefully  inspected  after  its  expulsion.  If  it  is  not 
intact,  the  obstetrician  may  introduce  his  finger  and  remove  the 
retained  portion,  thus  making  it  possible  for  the  uterus  to  con- 
tract properly  and  close  off  the  open  blood  vessels. 

Atony,  or  impaired  tone  of  the  uterine  muscles,  may  result  in 
hemorrhage  because  of  failure  of  the  muscle  fibres  to  constrict 
the  vessels.  Quite  evidently,  the  first  step  toward  controlling 
hemorrhage  from  this  cause  is  to  stimulate  the  muscles  to  con- 
tract ;  this  is  done  by  means  of  massage  and  the  administration  of 
pituitrin  and  ergot.  Elevation  of  the  foot  of  the  bed  and  appli- 
cation of  ice-bag  to  the  abdomen  are  also  employed. 

In  severe  cases,  the  doctor  may  give  an  intra-uterine  douche 
of  hot,  sterile  salt  solution  and  if  this  fails  he  may  pack  the  uterus 
tightly  with  sterile  gauze.  The  douche  and  pack  represent  opera- 
tive maneuvers  and,  therefore,  are  never  to  be  undertaken  by 
the  nurse.  Her  assistance  is  important,  however,  as  strictest 
asepsis  is  imperative  and  she  will  have  to  prepare  the  patient 
and  the  necessary  articles  with  the  greatest  care. 

Should  bleeding  become  profuse  during  the  doctor's  absence 
the  nurse  must  stay  with  the  patient  and  massage  the  fundus 
and  have  some  one  else  elevate  the  foot  of  the  bed  on  the  seat 
of  a  straight  chair  or  upon  firm  blocks  and  summon  the  doctor. 
In  anticipation  of  such  an  emergency  the  nurse  must  always 
have  an  understanding  with  the  doctor  about  the  administration 
of  pituitrin  and  ergot.  If  there  has  been  no  understanding,  and 
the  doctor  is  delayed  or  the  bleeding  becomes  alarmingly  profuse, 
the  nurse  will  usually  be  upheld  if  she  gives  1  cubic  centimetre 
of  pituitrin,  hypodermically  and  a  dram  of  ergot  by  mouth. 

It  is,  of  course,  definitely  understood  that  nurses  do  not 
give  medicines  without  orders,  but  a  single  dose  of  pituitrin 
and  ergot  upon  the  occurrence  of  a  profuse  hemorrhage  can 
scarcely  do  harm  and  may  actually  save  the  patient 's  life.    Such 


COMPLICATIONS  OF  THE  PUERPERIUM         393 

a  situation  is  an  emergency  fortunately  a  rare  one,  and  the 
nurse  will  have  to  be  quick-witted  and  use  the  best  judgment 
she  is  capable  of. 

The  patient  is  usually  more  or  less  shocked  by  the  time  the 
bleeding  has  been  controlled  and  needs  the  rest,  quiet  and  stimu- 
lation that  are  ordinarily  employed  in  such  cases.  She  should 
be  well  wrapped  in  blankets  and  surrounded  with  hot  water  bot- 
tles placed  outride  the  blankets,  watched  constantly  and  moved 
frequently;  salt  solution  or  strong  coffee  are  sometimes  given 
by  enema,  or  saline  infusions  or  intra-venous  injections  may  be 
given.  The  patient  must  be  kept  warm  and  quiet  and  pressed 
to  drink  large  amounts  of  fluids. 

But  above  all  the  nurse  must  remember  that  severe  hemor- 
rhage from  a  relaxed  uterus  can  almost  always  be  prevented  if 
the  fundus  is  kept  hard,  by  massage  when  necessary,  during  the 
first  hour  or  so  after  delivery. 

Puerperal  infection  is  usually  regarded  as  a  condition 
which  results  from  the  entrance  of  infective  bacteria  into  the 
female  generative  tract  during  labor  or  the  puerperium,  to  dis- 
tinguish it  from  other  infections  which  may  occur  coincidently 
with  the  puerperal  state,  but  not  necessarily  be  related  to  it. 

Puerperal  infection  is  one  of  the  most  destructive  and  most 
dreaded  of  the  complications  which  may  overtake  the  obstetrical 
patient,  and  has  evidently  been  so  considered  since  the  days  of 
Hippocrates.  Until  recent  years  this  veritable  scourge  was  so 
utterly  baffling  that  it  was  regarded  as  more  or  less  of  a  dis- 
pensation of  a  Divine  Providence  and  therefore  to  be  accepted 
with  the  same  philosophical  resignation  as  earthquakes  and 
cyclones. 

In  dramatic  contrast  to  this  unresisting  attitude  is  the  pres- 
ent knowledge  concerning  the  cause  and  prevention  of  this  dis- 
ease, and  the  general  belief  that  it  is  a  wound  infection  and 
therefore  practically  preventible;  that  it  is  to  be  ascribed  to 
the  carelessness  of  mankind  rather  than  to  the  indifference  of 
Providence. 

This  change  is  due  very  largely  to  the  devoted  work  of  three 
men  who  were  deeply  stirred  by  the  tragic  frequency  with  which 
young  women  laid  down  their  lives  in  so-called '  *  child  bed  fever." 


394  OBSTETRICAL  NURSING 

These  men  were  Ignaz  Semmelweiss,  Oliver  "Wendell  Holmes, 
better  known  to  Americans  as  poet  and  humorist,  and  Louis 
Pasteur,  each  contributing  his  own  special  observations  to  the 
sum  of  knowledge  which  was  to  mean  so  much  to  mothers  of 
the  future.  Also  the  theories  of  Lister  concerning  antisepsis 
and  the  inauguration  of  the  use  of  sterile  rubber  gloves  by  Dr. 
Halsted,  of  Johns  Hopkins  Hospital,  has  had  the  same  life-saving 
effect  upon  obstetrical  patients  as  upon  all  surgical  patients. 

In  1843,  Oliver  Wendell  Holmes  read  a  paper  before  the 
Boston  Society  for  Medical  Improvement,  entitled  "The  Con- 
tagiousness of  Puerperal  Fever."  In  this  paper  he  presented 
striking  evidence  that  in  many  instances,  something  was  con- 
veyed by  doctor  or  nurse,  from  an  ill  person  to  a  maternity 
patient  with  puerperal  fever  as  a  result.  He  was  attacked  and 
ridiculed  for  his  theories  and  some  of  the  leading  obstetricians 
declared  that  it  was  an  insult  to  their  intelligence  to  expect  them 
to  believe  that  creatures  too  small  to  be  seen  by  the  naked  eye 
could  work  such  havoc. 

In  1847  Ignaz  Semmelweiss,  of  the  Vienna  Lying-in  Hos- 
pital, decided  as  a  result  of  some  of  his  investigations  that  puer- 
peral infection  was  a  wound  infection,  and  that  the  infecting 
organisms  were  introduced  into  the  birth  canal  on  the  examining 
finger  of  the  doctor  or  nurse,  after  contact  with  an  infected  pa- 
tient or  cadaver.  Accordingly  he  required  that  all  vaginal  ex- 
aminations be  preceded  by  washing  the  hands  in  chlorid  of 
lime,  after  which  precautions  the  mortality  from  infection 
dropped  from  10  per  cent,  to  less  than  1  per  cent.  In  1867 
Semmelweiss  offered  his  theories  and  conclusions  in  a  masterly 
work  on  this  subject,  the  title  of  which  may  be  translated  as 
"The  Etiology,  Conception  and  Prophylaxis  of  Child-Bed 
Fever, ' '  but  the  actual  cause  of  the  disease  was  still  unknown. 

But  about  1879  Pasteur  demonstrated  what  is  now  known 
as  the  streptococcus,  in  certain  patients  suffering  from  puerperal 
fever. 

"Pasteur,"  wrote  M.  Roux,  "does  not  hesitate  to  declare  that  that 
microscopic  organism  (a  microbe  in  the  shape  of  a  chain  or  ehaplet) 
is  the  most  frequent  cause  of  infection  in  recently  delivered  women. 
One  day,  in  a  discussion  on  puerperal  fever  at  the  Academy,  one  of 


COMPLICATIONS  OF  THE  PUERPERIUM        395 

his  most  weighty  colleagues  was  eloquently  enlarging  upon  the  causes 
of  epidemics  in  lying-in  hospitals;  Pasteur  interrupted  him  from  his 
place.  'None  of  those  things  cause  the  epidemic;  it  is  the  nursing  and 
medical  staff  who  carrj^  the  microbe  from  an  infected  woman  to  a 
healthy  one.'  And  as  the  orator  replied  that  he  feared  that  microbe 
would  never  be  found,  Pasteur  went  to  the  blackboard  and  drew  a 
diagram  of  the  chain-like  organism,  saying:  'There,  that  is  what  it  is 
like!'  His  conviction  was  so  deep  that  he  could  not  help  expressing 
it  forcibly.  It  would  be  impossible  now  to  picture  the  state  of  surprise 
and  stupefaction  into  which  he  would  send  the  students  and  doctors  in 
hospitals,  when,  with  an  assurance  and  simplicity  almost  disconcerting 
in  a  man  who  was  entering  a  lying-in  ward  for  the  first  time,  he  criti- 
cised the  appliances,  and  declared  that  the  linen  should  be  put  into  a 
sterilizing  stove."  ^ 

Slowly,  but  very  slowly,  the  teachings  of  these  earnest  men 
were  adopted  by  the  medical  profession,  with  the  result  that  in 
well-conducted,  modern  hospitals  the  precautions  which  have 
been  described  in  preceding  chapters  are  rigidly  observed.  And 
to-day,  one  woman  in  about  1,000  in  such  hospitals  dies  of  puer- 
peral infection,  instead  of  one  in  ten,  as  in  the  early  days.  In 
the  year  1864,  23  per  cent,  of  the  patients  at  the  Maternite,  in 
Paris,  died  of  puerperal  infection. 

But  unhappily,  the  decline  in  the  occurrence  of  puerperal 
infection,  in  this  country  is  largely  confined  to  the  hospitals,  for 
in  the  homes  throughout  the  land  the  disease  is  almost  as  com- 
mon as  it  was  in  the  days  of  our  fathers,  or  even  grandfathers. 
Of  approximately  20,000  deaths  from  childbirth  in  this  country 
during  1920,  about  one-half,  or  possibly  10,000  were  from  puer- 
peral infection. 

To  the  nurse  there  is  considerable  significance  in  Pasteur's 
cJiaracterization  of  the  infected  young  mother  as  an  "invaded 
patient,"  for  the  nurse's  preparation  for  labor  and  her  care 
of  the  patient  during  the  puerperium  should  be  enormously  influ- 
ential in  preventing  this  "invasion."  In  this  connection  she 
may  well  ponder  Miss  Nightingale's  assertion  that  "The  fear 
of  dirt  is  the  beginning  of  good  nursing. ' '  Certainly  the  obstet- 
rical patient  cannot  be  well  cared  for  unless  the  nurse  has  this 
fear  in  her  heart. 

' ' '  The  Life  of  Pasteur, ' '  by  Vallery  Eadot. 


396  OBSTETRICAL  NURSING 

Puerperal  infection,  then,  in  the  light  of  present  informa- 
tion, is  regarded  as  a  wound  infection  caused  by  the  strepto- 
coccus, gonococcus,  colon  bacillus,  gas  bacillus  or  any  other  pus 
producing  organism.  Of  these,  the  streptococcus  infection  is 
the  most  frequently  seen  and  is  also  the  most  serious,  about  10 
per  cent,  of  such  infections  resulting  fatally;  while  the  gon- 
orrheal infection,  though  seldom  ending  in  death,  usually  causes 
sterility. 

Infection  during  the  puerperium  occurs  most  often  in  the 
uterus,  and,  if  mild,  may  amount  to  nothing  more  than  endome- 
tritis, or  inflammation  of  the  uterine  lining.  In  more  serious 
cases,  the  inflammation  may  spread  to  the  tubes  and  ovaries; 
may  cause  abscesses  in  the  broad  ligament  and  general  perito- 
nitis. A  streptococcus  infection  may  spread  through  the  lym- 
phatics and  cause  general  septicemia. 

Infection  of  the  raw  and  bleeding  placental  site  may  occur 
at  any  time  during  labor  or  the  ten  days  following,  though  the 
danger  of  infection  decreases  steadily  after  the  first  day  post- 
partum. 

S3nnptoins.  The  symptoms  vary  greatly  according  to  the 
infecting  organism  and  according  to  the  site  and  extent  of  the 
inflammation.  In  mild  types  of  infection,  the  patient  may  be 
entirely  normal  for  the  first  three  or  four  days  and  then  com- 
plain of  chilliness  or  even  have  a  chill ;  her  temperature  will  be 
slightly  above  normal,  finally  reaching  about  101°  F.,  where  it 
hovers  for  ten  days  or  two  weeks,  after  which  it  drops  again 
to  normal  and  the  patient  recovers. 

The  severe  type,  which  is  so  dreaded,  is  the  one  in  which  the 
patient  is  normal  until  the  third  or  fourth  day  when  she  com- 
plains of  tenderness,  chilliness,  weariness,  and  of  being  gen- 
erally wretched.  She  may  complain  of  chilliness  but  more  often 
has  a  chill. 

The  pulse  is  usually  rapid  and  the  temperature  goes  up 
somewhat  abruptly.  (Chart  3.)  The  condition  of  the  lochia 
depends  upon  the  infecting  organism.  In  streptococcal  infec- 
tion the  lochia  is  often  greatly  decreased  in  amount  and  almost 
odorless,  while  in  colon  bacillus  infections  the  lochia  is  profuse 
and  foul-smelling.     The  attack  may  be  very  acute  and  result 


COMPLICATIONS  OF  THE  PUERPERIUM         397 


fatally  in  a  few  days,  or  it  may  gradually  subside  and  the 
patient  recover. 

In  gonorrheal  infections  the  temperature  does  not  go  up  until 
later,  from  the  sixth  or  to  the  tenth  day,  as  a  rule.  (Chart  4.) 
The  patient  is  not  usually  very  ill  and  generally  recovers.  But 
the  gonococcus  is  very  likely  to  produce  an  inflammation  of  the 


m>i 


Name     CLww  VS^  \-»  ©. W  \^  v 
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Chart  No.  3. — Chart  showing  rise  in  temperature  about  3rd  day  after 
delivery  in  a  streptococcus  infection.. 


398 


OBSTETRICAL  NURSING 


tubes  and  to  close  up  the  fimbriated  opening.  Thus  it  is  im- 
possible for  ova  thereafter  to  enter  the  tube  and  gain  access  to 
the  uterus  and  accordingly  the  patient  cannot  again  become 
pregnant.  Unlike  other  infections,  gonorrhea  is  not  conveyed 
to  the  patient  during  or  soon  after  labor  on  instruments  or 
examining  fingers,  but  is  already  present  in  the  vulvo-vaginal 


Name. 


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Chart  No.  4. — Chart  showing  rise  in  temperature  about  7th  day  after 
delivery  in  gonorrheal  infection. 


COMPLICATIONS  OF  THE  PUERPERIUM         399 

glands  and  from  tlicm  may  travel  to  the  uterine  cavity  and  to 
the  tubes. 

Treatment  and  Nursing  Care.  Preventive.  There  is  so  lit- 
tle that  i-aii  l)e  done  toward  curing  a  patient  suffering  from 
puerperal  infection  that  the  greatest  effort  should  be  made  to 
prevent  the  disease.  The  nurse's  part  in  preventing  this  com- 
plication is  an  important  one  and  consists  of  making  such  prep- 
aration for  labor  that  it  may  be  conducted  with  absolute  cleanli- 
ness; maintaining  the  same  asepsis  during  delivery  as  she  would 
throughout  a  major  surgical  operation  and  protecting  the 
perineum  from  infection  after  delivery. 

Curative.  The  curative  treatment  for  puerperal  infection 
resolves  itself  largely  into  good  nursing  care.  The  patient  should 
be  kept  warm  and  quiet  and  as  comfortable  as  possible ;  elimina- 
tion is  promoted,  her  strength  is  saved  and  her  general  resis- 
tance increased  in  everj'  way  possible.  The  head  of  the  bed  is 
frequently  elevated,  to  promote  drainage ;  the  windows  are  kept 
open  to  provide  plenty  of  fresh  air ;  the  diet  is  light  and  nourish- 
ing and  the  patient  is  encouraged  to  drink  an  abundance  of 
water.  Ice  caps  to  the  head  and  abdomen  are  frequently  used 
to  make  the  patient  more  comfortable;  also  cold  sponge  baths 
when  the  temperature  is  high. 

A  patient  suffering  from  puerperal  infection  should  be  con- 
scientiously isolated.  If  the  nurse  who  cares  for  her  is  forced 
to  come  in  contact  with  other  patients,  she  should  wear  gloves 
and  a  gown  while  attending  the  infected  woman  and  thoroughly 
scrub  and  soak  her  hands  after  each  attention. 

It  was  formerly  the  practice  to  curette  the  patient  suffering 
from  puerperal  infection,  and  give  intra-uterine  douches,  but 
it  is  now  pretty  generally  believed  that  neither  of  these  pro- 
cedures does  any  appreciable  good,  but  on  the  other  hand  may 
do  harm.  The  objection  to  curettage  is  on  the  ground  that  by 
this  means  the  protective  w^all  which  Nature  has  developed  to 
prevent  the  further  invasion  of  bacteria  into  the  uterine  tissues, 
is  removed  and  a  new  bleeding  area  is  provided  for  further  and 
easy  development  of  the  inflammation. 

Antiseptic  douches  seem  to  be  useless,  for  if  they  are  strong 
enough  to  be  germicidal  they  are  likely  to  injure  the  tissues  and 


400  OBSTETRICAL  NURSING 

also  do  harm  by  being  absorbed  into  the  system;  while  weaker 
solutions  will  not  destroy  the  organisms  but  are  likely  to  carry 
more  infective  material  up  into  the  uterus.  In  cases  of  putrid 
endometritis,  however,  if  the  doctor  cleans  out  the  uterus  with 
his  finger,  a  douche  of  sterile  salt  solution  is  often  given  for 
the  purpose  of  removing  any  putrefactive  material  which  may 
"have  been  left  behind. 

Phlegmasia  alba  dolens  or  "milk  leg."  In  some  cases 
of  puerperal  infection,  thrombi  are  formed  in  the  veins  of  the 
pelvis,  from  which  particles  may  be  broken  off  and  carried  to 
various  parts  of  the  body  and  cause  phlebitis  or  even  abscesses. 
If  thrombi  lodge  in  the  large  vessels  of  the  thigh,  the  interfer- 
ence of  the  venous  circulation  results  in  swelling  and  tenderness 
of  the  leg  which  is  often  referred  to  as  "milk  leg."  This  con- 
dition is  rather  rare  and  does  not  usually  appear  until  the  second 
or  third  week  after  delivery. 

The  swelling  ordinarily  starts  at  the  foot  and  gradually 
extends  up  to  the  thigh.  The  patient  complains  of  pain  in  the 
calf  of  her  leg  and  she  may  have  an  elevated  temperature,  rapid 
pulse  and  the  general  wretchedness  associated  with  an  infection. 

The  main  feature  of  the  treatment  is  rest  in  bed ;  the  patient 
should  be  kept  there  for  at  least  a  week  after  her  temperature 
becomes  normal ;  her  leg  should  be  elevated,  wrapped  in  cotton 
batting  and  the  bedclothes  held  from  it  by  means  of  a  bed  cradle 
or  some  sort  of  a  light  frame.  The  nurse  should  never  rub  the 
affected  leg,  and  the  patient  should  also  be  cautioned  against 
this  for  fear  of  dislodging  a  particle  of  the  thrombus  and  causing 
an  embolism  elsewhere,  possibly  in  the  lungs.  For  the  same 
reason,  the  patient  must  be  warned  not  to  make  sudden  or  vio- 
lent movements  for  some  time  after  she  is  allowed  to  be  up  and 
about,  but  to  walk  and  move  rather  slowly.  The  swelling  and 
discomfort  may  subside  in  a  few  weeks  or  they  may  persist  for 
months. 

Puerperal  Mania.  A  word  about  extreme  mental  unbalance 
during  the  puerperium  is  worth  while  at  this  point  because  the 
nurse  will  frequently  hear  of  this  distressing  condition,  and 
will  almost  inevitably  come  in  contact  with  it  at  some  time.  It 
was  formerly  believed  that  there  were  certain  mental  disorders 


COMPLICATIONS  OF  THE  PUERPERIUM         401 

which  were  peculiar  to  pregnancy  and  the  puerperium,  but  this 
belief  has  given  way  before  the  present  knowledge  of  psychiatry. 

The  puerperal  patient  is  sometimes  delirious  and  violent  for 
longer  or  shorter  periods  of  time,  but  apparently  these  condi- 
tions are  due  to  toxemia  or  fever,  or  a  mental  unbalance  has 
resulted  from  her  reaction  to  the  idea  of  motherhood,  just  as 
it  would  have  resulted  from  an  equal  strain  of  some  other  char- 
acter. 

In  other  words,  the  young  mother  may  suffer  mental  derange- 
ment from  the  same  causes  that  would  produce  this  state  in 
any  other  person,  but  not  from  causes  or  conditions  which  are 
peculiar  to  the  puerperium. 

If  the  excitement  or  delirium  are  due  to  a  toxemia,  they  are 
relieved  by  treating  the  cause,  while  from  the  nurse 's  standpoint 
the  care  would  be  the  same  as  for  any  delirious  patient.  The 
patient  should  not  be  left  alone  and  she  should  be  protected 
against  doing  herself  any  injury. 

A  mental  disturbance  which  is  due  to  the  patient's  inability 
to  adjust  herself  to  the  state  of  motherhood,  and  all  that  that 
implies  to  her,  is  a  different  matter,  and  is  discussed  in  the  chap- 
ter on  mental  hygiene. 


"Sympathy  with,  interest  in  the  poor  so  as  to  help  them, 
can  onty  be  got  by  long  and  close  intercourse  in  their  own  houses 
— not  patronizing — not  'talking  down'  to  them — not  'prying 
about' — sympathy  which  will  grow  in  insight  and  love  with 
every  visit." — Florence  Nightingale. 


PART  VI 
THE  MATERNITY  PATIENT  IN  THE   COMMUNITY 

CHAPTER  XIX.  ORGANIZED  PRENATAL  WORK.  Mortality  in  Child- 
bearing.  Aims  of  Prenatal  Care.  Difficulties:  Educational,  Eco- 
nomic, Social,  Professional.  Prenatal  Work  in  Other  Countries. 
Progress  of  Prenatal  Work  in  this  Country.  The  Women's  Mu- 
nicipal League  of  Boston.  Maternity  Centre  Association  of  New 
York.  Routine  and  Methods.  Results.  The  Situation  in  the  Country 
as  a  Whole.  Prenatal  Care  in  Rural  Communities.  Forms  and 
Routines  used  by  Maternity  Centre  Association,  New  York  City. 

CHAPTER  XX.  HOME  DELIVERIES  AND  CARE  OF  THE  YOUNG 
MOTHER  BY  VISITING  NURSES.  Forms  and  Routines  of  the 
Philadelphia  Visiting  Nurse  Society. 


CHAPTER  XIX 
ORGANIZED  PRENATAL  WORK 

The  foregoing  discussions  of  prenatal  care  and  the  principal 
complication h  of  pregnancy,  and  the  dangers  to  which  expectant 
mothers,  young  mothers  and  their  babies  are  exposed,  bring  us 
sharply  face  to  face  with  the  questions,  "What  can  be  done 
about  it?"  "What  is  being  done  about  it?"  and,  "Is  anything 
more  possible?" 

We  have  considered  the  problem,  and  the  remedy,  at  very 
close  range;  that  is,  from  the  standpoint  of  the  individual  pa- 
tient. We  are  now  concerned  to  know  whether  or  not  the  remedy, 
in  the  shape  of  care  and  supervision  during  pregnancy,  may  be 
extended  in  proportion  to  the  enormous  multiplication  of  the 
problem,  when  instead  of  one  patient  we  must  think  of  millions. 
In  other  words,  is  country-wide  prenatal  care,  with  all  that  it 
implies,  practicable?     And  if  so,  by  what  means  or  method? 

Let  us  review  the  problem  for  a  moment,  and  acknowledge 
the  pathos  and  tragedy  of  it. 

Child-bearing  is  so  dangerous,  under  present  conditions  in 
this  country,  that  it  stands  second  only  to  tuberculosis  as  a  cause 
of  death  among  women  between  the  ages  of  15  and  44.  The 
discharge  of  woman's  supreme  function  is  apparently  very 
hazardous. 

Dr.  Dublin  summarizes  as  follows  the  rate  at  which  mothers 
die  throughout  the  country  at  large : 

1.  ''More  than  seven  women  die  from  disorders  of  pregnancy  or 
childbirth  out  of  each  1,000  confinements.  This  is  equivalent 
to  one  maternal  death  out  of  every  140  confinements.  (About 
20,000  in  1920.) 

2.  "Forty-five  babies  out  of  every  1,000  births,  or  one  out  of  every 
22,  are  born  dead.     (About  112,000  annually.) 

3.  "Forty  babies  out  of  every  1,000  born  alive,  die  before  they  are 
one  month  old.     (About  100,000  annually.) 

"Such  ai'e  the  dangers  to  mother  and  infant  at  the  present  time." 

405 


406  OBSTETRICAL  NURSING 

And  then,  as  though  in  answer  to  our  question,  "What  can 
be  done  about  it?"  he  states  that,  "among  women  who  receive 
prenatal  and  maternal  care  under  skilled  direction : 

1.  Only  two  women  instead  of  seven  die  out  of  every  1,000  confine- 
ments, 

2.  Only   twelve  babies,   instead  of  45,  are  still-born  in  every  1,000 
births, 

3.  Only  ten  babies,  instead  of  40  per  1,000  born  alive,  die  before 
they  are  one  month  old. 

Obviously,  then,  only  a  few — too  few — American  women  are 
receiving  the  minimum  of  care  that  makes  child-bearing  a  rea- 
sonably safe  adventure. 

Perhaps  it  will  be  w^ell  for  the  nurse  to  pause  just  here  for 
a  fresh  reminder  that  the  end  really  to  be  desired  through  pre- 
natal care  is  not  so  much  the  mere  prevention  of  death  among 
mothers  and  infants,  as  the  promotion  of  health,  as  well;  our 
charges  must  be  not  only  saved  but  saved  to  mental  and  physical 
health,  vigor  and  well-being,  capable  of  being  useful,  productive 
citizens.  Happily,  both  life  and  health  are  conserved  by  the 
same  measures,  and  effort  toward  either  end  helps  to  accom- 
plish both. 

Although  the  inhabitants  of  a  prosperous  country  like  the 
United  States  should  be  a  hardy  people,  the  results  of  medical 
examinations  by  the  draft  boards,  during  the  war,  gave  us  a 
rude  awakening  to  the  fact  that  they  are  not. 

An  appallingly  large  number  of  young  men  who  were  passing 
in  every  day  life  as  normal  were  found  to  be  physically  unfit  for 
military  service.  And  we  know  that  a  large  part  of  this  unfitness 
resulted  from  inadequate  care,  of  some  kind,  during  the  weeks 
and  months  that  compi-ise  the  beginning  of  life. 

It  can  scarcely  be  doubted  that  the  most  critical  period  in  the 
life  history  of  the  individual  is  the  first  ten  months — the  nine 
months  of  intra-uterine  life  and  the  first  month  after  birth. 
Good  care,  then,  during  this  critical  period  is  indispensable  in 
the  building  of  a  healthy  race.  The  difficulty  in  the  way  of 
giving  this  care,  at  present,  seems  to  be  fourfold :  educational, 
economic,  social  and  professional,  and  may  be  summed  up  some- 
what as  follows: 


ORGANIZED  PRENATAL  WORK  407 

1.  From  the  educational  standpoint,  almost  universal  ignorance 
of  the  need  of  skilled  obstetrical  care. 

2.  From  the  economic  standpoint,  financial  inability  of  the  average 
woman  to  afl'md  such  care. 

3.  From  the  social,  or  administrative,  standpoint,  a  fairly  general 
failure  on  the  part  of  public  authorities  to  recognize  the  situa- 
tion as  one  of  grave  national  importance. 

4.  From  the  professional  standi)oint,  inadequacy  of  available 
obstetrical  service,  both  medical  and  nursing. 

In  many  of  the  large  cities  women  have  access  to  excellent 
obstetrical  and  prenatal  care;  both  those  who  can  pay  for  it 
and  also  the  poor  woman  who  cannot,  though  very  many  in 
both  groups  still  fail  to  take  advantage  of  the  opportunities  that 
are  open  to  them. 

But  the  city  women  of  moderate  means,  and  those  in  small 
towns  and  rural  communities  are  in  general  unprovided  for. 
And  it  is  their  babies  who  grow  up  and  later  constitute  the 
backbone,  w^eak  or  strong,  of  the  nation. 

Certain  foreign  countries  which  have  evinced  more  concern 
for  the  welfare  of  mothers  and  babies  than  has  the  United 
States  have  demonstrated  that  widespread  prenatal  care  is  en- 
tirely possible  and  practicable,  and  they  regard  it  also  as  an 
imperative  measure  toward  promoting  the  national  welfare. 

The  actual  origin  of  this  prenatal  care  is  somewhat  difficult 
to  locate.  There  are  the  consultations  for  pregnant  women  in- 
stituted in  Paris  several  years  ago  by  Dr.  Budin.  But  Dr. 
Ballantyne,  of  Edinburgh,  is  generally  regarded  as  the  father 
of  the  prenatal  w^ork  because  of  his  work  on  abnormalities  of 
pregnancy  and  his  insistence  upon  the  importance  of  what  might 
be  accomplished  through  intelligent  care  and  supervision  of  all 
women,  not  alone  abnormal  cases,  throughout  pregnancy. 

In  England  for  nearly  twenty  years  the  supervision  and  in- 
stuction  of  expectant  mothers  has  been  an  integral  part  of  the 
work  of  midwives  who  are  trained,  registered  and  controlled 
by  government  authority.  Of  late  the  work  among  mothers  and 
babies  has  been  so  extended  that  during  the  war,  always  a  de- 
structive period  for  babies,  the  infant  death  rate  was  reduced 
to  the  lowest  figure  in  the  country's  history.  This  was  accom- 
plished partly  through  a  maternity  benefit  which  helped  the 


408  OBSTETRICAL  NURSING 

mother  to  pay  for  obstetrical  care,  and  partly  through  indirect 
government  aid,  in  the  form  of :  compulsory  notification  of 
births;  a  great  increase  in  the  number  of  "health  visitors''  and 
welfare  centres,  and  government  grants  to  local  authorities  which 
defrayed  half  the  expense  of  giving  prenatal,  natal  and  post- 
natal care  and  of  instructing  mothers  in  the  care  of  themselves 
and  their  babies.  Especial  effort  has  been  made  to  help  the 
mothers  in  rural  sections ;  more  small  hospitals  being  maintained, 
more  physicians  being  provided  and  assistance  given  in  caring 
for  older  children,  during  the  mother's  absence,  if  she  was 
obliged  to  go  to  a  hospital  at  the  time  of  delivery. 

New  Zealand  also  has  made  marked  progress  in  its  work  of 
saving  the  lives  and  promoting  the  health  of  its  mothers  and 
babies,  having  at  present  the  lowest  infant  death  rate  in  the 
world.  This  has  been  brought  about  largely  through  the  efforts 
of  the  "Society  for  the  Health  of  Mothers  and  Children,"  an 
organization  employing  visiting  nurses,  called  Plunkett  Nurses, 
in  honor  of  the  family  by  that  name  which  has  greatly  aided 
the  work. 

The  outstanding  features  of  this  work  are  educational  and 
preventive;  the  mothers  being  instructed  from  early  in  preg- 
nancy about  the  care  of  themselves  and  the  preparation  for, 
and  subsequent  care  of  their  babies.  Prenatal  clinics  are  main- 
tained and  the  facilities  for  hospital  care  are  being  steadily 
increased  and  improved. 

One  is  impressed  by  the  spirit  animating  this  organization, 
as  expressed  in  a  statement  of  its  "functions,"  one  of  which  is 
as  follows :  "To  uphold  the  saeredness  of  the  body  and  the  duty 
of  health,  to  inculcate  a  lofty  view  of  the  responsibilities  of  ma- 
ternity and  the  duty  of  every  mother  to  fit  herself  for  the  per- 
fect fulfillment  of  the  natural  calls  of  motherhood,  both  before 
and  after  childbirth,  and  especially  to  advocate  and  promote  the 
breast  feeding  of  infants."  Work  based  upon  such  idealism 
could  not  but  be  effective. 

The  New  Zealand  undertaking  is  regarded  as  patriotic,  rather 
than  philanthropic,  and  mothers  who  are  visited  and  cared  for 
are  accordingly  encouraged  to  pay  for  tliis  service,  if  financially 
able  to  do  so.    The  Government  supervises  and  warmly  supports 


ORGANIZED  PRENATAL  WORK  409 

the  work  of  this  Society  and  also  aids  by  enforcing  the  most 
perfect  system  of  birth  registration  in  the  world,  without  which 
the  results  of  the  work  could  not  be  accurately  gauged. 

England  and  New  Zealand,  as  countries,  have  pointed  the 
way  toward  accomplishing  a  nation-wide  reduction  of  maternal 
and  infant  mortality  and  morbidity  by  making  provision  for 
widely  organized  prenatal  care.  They  recognize  the  problem 
as  one  of  public  concern.  They  get  at  the  heart  of  it :  ignorance 
on  one  hand  and  poor  or  inadequate  care  on  the  other.  They 
apply  a  practical  solution,  comprising  a  system  of  preventive, 
instructive  prenatal  care,  together  with  improved  and  increased 
facilities  for  medical  and  nursing  care  at  the  time  of  delivery 
and  afterward. 

This  country  has  been  strangely  laggard  in  making  wide- 
spread, organized  effort  along  these  lines,  to  safeguard  its  mothers 
and  babies,  through  prenatal  care.  But  sporadic,  volunteer 
effort  has  been  made  in  certain  cities,  and  has  been  crowned  with 
brilliant  success. 

The  first  of  these  attempts  in  this  country  was  made  in  Bos- 
ton, in  1909,  with  a  maternity  nurse  working  under  the  auspices 
of  the  Women 's  Municipal  League.  The  work,  which  was  estab- 
lished by  Mrs.  William  Lowell  Putnam,  was  designed  to  show 
what  could  be  accomplished  by  intensive  work  in  a  small  group 
of  city  mothers,  and  suggest  the  feasibility  of  its  extension  to 
larger  numbers. 

"The  routine,  which  has  been  evolved  through  a  five-year 
experiment  by  the  Prenatal  Committee  of  the  Women's  Munici- 
pal League, ' '  says  Mrs.  Putnam,  ' '  has  reduced  the  infant  deaths, 
among  those  cared  for  by  a  third  to  one-half,  as  compared  with 
cases  not  receiving  this  care.  Still-births  have  been  cut  in  half. 
Premature  births  have  been  reduced  to  seven-tenths  of  one  per 
cent.  These  results  were  obtained  by  supervision  during  preg- 
nancy only,  and  at  a  cost  of  less  than  $3.00  per  patient ;  an  ex- 
pense which  the  patients  were  always  encouraged  to  meet  if 
possible. 

*  *  The  success  of  this  venture  proved  to  be  so  satisfactory  that 
the  Boston  workers  have  gone  still  further  toward  supplying 
the  needs  of  mothers  and  babies  by  adding  to  the  prenatal  care, 


410  OBSTETRICAL  NURSING 

care  at  the  time  of  birth  and  afterwards  until  the  mother  is 
again  on  her  feet.  Through  the  courtesy  of  one  of  the  largest 
Boston  hospitals,  a  clinic  is  held  weekly  in  its  Out-Patient  De- 
partment. The  hospital  is  in  no  way  responsible  for  the  clinic, 
simply  lending  the  room  in  which  the  clinics  are  held.  The 
medical  care  at  the  clinic  and  in  the  patients'  homes  is  given  by 
obstetricians  from  the  staff  of  the  Boston  Lying-in  Hospital. 
Medical  examinations  are  made  during  pregnancy  at  the  clinic, 
and  a  nurse  visits  and  instructs  the  patient  during  the  period 
of  expectancy,  always  under  the  direction  of  a  physician.  The 
delivery  is  performed  in  the  home  hy  a  physician  connected  with 
the  clinic,  at  which  the  nurse  also  is  in  attendance.  She  visits 
the  mother  and  baby  twice  daily  for  three  days  subsequent  to 
the  delivery,  gradual!}^  making  her  visits  less  frequent  there- 
after. The  doctor  pays  from  two  to  four  postnatal  visits,  as 
may  be  needed.  For  this  prenatal,  natal  and  postnatal,  medical 
and  nursing  care,  $40.00  is  the  entire  amount  charged,  and  the 
work  is  self-supporting  with  the  nurse's  time  filled.  Prenatal 
care,  alone,  is  given  if  desired  by  a  physician  and  with  visits  at 
the  clinic  included ;  the  charge  for  this  service  is  $10.00. ' ' 

I  refer  to  the  work  in  Boston,  particularly,  as  its  inaugura- 
tion by  Mrs.  Putnam  marked  the  beginning  of  this  branch  of 
public-health  work  in  this  country,  though  to-day  the  same  kind 
of  service  is  available  to  expectant  mothers  in  many  of  the  large, 
and  some  of  the  smaller  cities.  Visiting  nurse  associations,  the 
country  over  are  giving  postnatal  and  infant  care  (in  some  in- 
stances, excellent  prenatal  care,  too),  often  providing  for  or 
assisting  with  the  deliveries,  and  effecting  an  enormous  saving 
of  life  and  health  by  so  doing.  But  the  number  of  patients  who 
are  cared  for  by  each  organization  is  relatively  so  small  that 
even  the  aggregate  of  the  work  done  readies  a  pathetically 
small  proportion  of  the  mothers  and  babies  in  the  country  as  a 
whole  who  need  care. 

The  first  comprehensive  effort,  in  the  United  States,  to  meet 
the  need  of  all  expectant  mothers  in  an  entire  community,  was 
inaugurated  in  New  York  City,  in  1918,  by  the  Maternity  Centre 
Association,  the  chief  function  of  the  organization  being  to  co- 
ordinate the  work  of  agencies  already  in  existence. 


ORGANIZED  PRENATAL  WORK  411 

This  Association  was  formed  as  a  result  of  the  work  of  the 
Maternity  Protective  Committee  of  the  Women's  City  Club  and 
the  Maternity  Service  Association  of  Physicians  and  Hospital 
Superintendents. 

The  foi-ni  of  organization,  purpose  and  methods  of  work  of 
this  association  may  be  studied  with  profit,  for  having  been 
started  on  a  small  scale  as  an  experiment,  it  now  constitutes  a 
demonstration  of  how,  through  co-ordinated  effort,  prenatal  and 
obstetrical  care  may  be  extended  almost  indefinitely  to  expectant 
mothers  in  urban  districts,  and  at  a  low  cost. 

The  purpose  and  scope  of  the  work  are  described  by  Miss 
Anne  Stevens,  its  former  Director,  who  tells  us  "that  it  is  the 
aim  of  the  Association  to  cover  completely  the  need  for  maternity 
care,  prenatal,  delivery  and  postnatal,  in  a  given  community,  by 
providing  for  every  woman  in  that  community,  medical  super- 
vision and  nursing  care  from  the  beginning  of  her  pregnancy 
until  her  bab}'  is  one  month  old.  This  is  being  attempted,  not 
by  establishing  another  medical  and  nursing  agency,  but  by  estab- 
lishing a  centre  through  which  the  maternity  work  of  every  hos- 
pital, private  physician,  midwife  and  nursing  agency  in  the 
community  may  be  co-ordinated  and  developed  to  its  fullest  ex- 
tent; a  centre  at  which  there  will  be  a  complete  record  of  every 
pregnancy  in  that  district ;  a  centre  from  which  the  whole  com- 
munity may  be  educated  to  realize  the  need  of  and  to  demand 
adequate  medical  supervision  and  nursing  care  for  every  woman 
and  her  baby  before  and  after  birth. ' ' 

It  is  not,  then,  an  experiment  in  prenatal  clinics,  many  of 
which  have  been  conducted,  both  in  New  York  and  elsewhere; 
but  it  is  an  experiment  in  its  attempt  to  provide  adequate  care 
for  every  pregnant  woman  in  the  community  from  the  begin- 
ning of  her  pregnancy  until  her  baby  is  a  month  old. 

Standards  for  adequate  prenatal  care,  upon  which  to  base 
the  work,  were  formulated  by  the  Maternity  Service  Association 
of  Physicians.  The  nurses  worked  with  these  standards  as  a 
guide  and  gradually  develoi)ed  detailed  i-outines,  as  a  result  of 
frequent  conferences  over  the  difficulties  and  problems  arising 
in  the  course  of  their  daily  work  among  the  patients. 

These  various   adaptations  were,   of  course,   approved  and 


412  OBSTETRICAL  NURSING 

authorized  by  the  Medical  Board  of  the  Association.  Because 
these  routines  meet  the  doctor's  requirements  so  satisfactorily, 
and  have  been  evolved  out  of  the  experience  of  many  nurses, 
concentrating  their  best  efforts  upon  this  Avork,  they  are  copied 
on  pages  423  to  436  with  the  belief  that  they  will  be  suggestive, 
and  perhaps  save  time  and  effort  for  those  who  may  wish  to  inau- 
gurate similar  work. 

Every  effort  is  made  by  the  Association  to  reach  all  of  the 
expectant  mothers  in  the  ten  zones  into  which,  for  the  purposes 
of  the  work,  the  Borough  of  Manhattan  was  divided  by  the  pre- 
liminary committee  ^  called  by  Dr.  Haven  Emerson,  who  at  that 
time  was  Commissioner  of  Health  for  New  York  City.  This 
Committee  was  called  for  the  purpose  of  surveying  the  obstet- 
rical facilities  of  Manhattan,  and  offering  suggestions  as  to  how 
they  might  be  utilized  in  an  effort  to  decrease  the  persistently 
high  infant  mortality. 

Patients  are  reported  for  care  by  hospitals,  dispensaries, 
clinics,  relief  agencies,  church  clubs,  settlements  and  the  like 
and  are  discovered  in  various  ways  by  the  nurses  on  their  rounds. 

The  nurse 's  first  visit  to  a  patient  is  little  more  than  a  friendly 
one.  In  fact,  she  may  have  to  make  several  such  calls  before  she 
is  able  to  so  far  win  the  patient 's  confidence  and  friendship  that 
she  will  consent  to  place  herself  under  supervision.  For  in  addi- 
tion to  obtaining  her  verbal  consent,  the  establishment  of  this 
sympathetic  relationship  is  found  to  be  necessary  before  the 
nurse  can  feel  sure  that  the  patient  will  freely  tell  of  her  symp- 
toms and  follow  the  advice  given. 

Before  making  plans,  or  talking  to  the  patient  about  pre- 
natal care,  the  nurse  ascertains  what  arrangements,  if  any,  the 
patient  herself  has  made  for  care  at  the  expected  confinement. 
She  finds  that  the  expectant  mothers  fall  into  four  groups : 

1.  Those  who  have  registered  with  a  hospital, 

2.  Those  who  have  arranged  to  be  cared  for  by  a  physician. 

3.  Those  who  have  arranged  to  be  eared  for  by  a  midwife. 

4.  Those  who  have  made  no  arrangements  of  any  kind. 

The  nurse's  relation  to  a  patient  registered  with  a  hospital 

*  The  Committee  consisted  of  Drs.  J.  Clifton  Edgar,  Ralph  Lobenstein 
and  Philip  Van  Ingea. 


ORGANIZED  PRENATAL  WORK  413 

for  delivery  depends  upon  the  scope  of  the  work  of  that  particu- 
lar institution.  Some  hospitals  will  register  patients  early  in 
pregnancy,  and  assume  the  entire  medical  and  nursing  care  and 
supervision  from  that  time  until  after  the  baby  is  born.  The 
Maternity  Centre  nurse,  obviously,  has  no  responsibility  for 
these  patients.  But  she  does  give  nursing  care  and  instruction 
to  patients  registered  with  hospitals  which  have  not  facilities 
for  prenatal  clinics  or  visiting  nurses  to  send  into  the  patients' 
homes.  The  hospital  resident,  in  these  cases,  assumes  responsi- 
bility for  medical  supervision  of  the  patients  and  receives  a  re- 
port from  the  Maternity  Centre  upon  each  nursing  visit ;  and 
the  nurse  in  turn  urges  the  patient  to  return  to  the  hospital, 
periodically,  to  see  the  doctor,  in  accordance  with  instructions 
received  from  the  hospital. 

This  form  of  co-operation  has  proved  to  be  so  satisfactory 
that  many  hospitals  now  do  not  wait  for  the  Maternity  Centre 
nurses  to  discover  patients  registered  with  them,  but  each  day 
notify  the  nurses  of  newly  registered  patients  and  ask  that  they 
be  given  the  routine  nursing  care  and  supervision  by  a  Ma- 
ternity Centre  nurse. 

When  a  nurse  finds,  upon  her  first  visit  to  a  patient,  that 
she  has  engaged  a  physician  to  attend  her  at  the  time  of  con- 
finement, she  gives  no  advice,  but  sends  to  the  doctor  a  form 
letter,  prepared  by  the  Medical  Board,  offering  to  nurse 
that  patient  according  to  the  routine  of  the  Maternity 
Centre  Association  if  he  wishes,  and  to  report  to  him  upon  each 
nursing  visit.  A  very  small  percentage  of  physicians  refuse  this 
offer  of  assistance,  the  majority  accepting  it  with  eagerness. 
Patients  who  have  engaged  their  own  physician  for  delivery, 
naturally,  are  not  asked  to  go  to  the  Maternity  Centre  clinics 
for  medical  examination  or  advice,  but  are  invited  to  go  for  the 
nurse's  instructions,  and  to  attend  the  group  conferences  that 
will  be  described  later. 

If  the  patient  belongs  to  the  third  group,  having  engaged  a 
midwife,  the  nurse  goes  in  person  to  see  the  midwife,  as  letters 
are  usually  of  little  avail.  She  asks  the  midwife  to  bring  her 
patient  to  the  clinic,  explaining  that,  though  midwives  are  taught 
to  conduct  deliveries,  they  are  not  taught  to  make  the  examina- 


414  OBSTETRICAL  NURSING 

tions  that  are  now  known  to  be  so  important  to  the  futnre  wel- 
fare of  mothers  and  balnes,  but  that  such  examinations  can  be 
made  at  the  clinic  by  the  doctor.  If  the  initial  examination  dis- 
closes any  abnormality,  this  fact  is  explained  to  the  midwife 
and  also  that  the  rules  governing  her  practice  forbid  her  caring 
for  such  a  patient.  The  nurse,  midwife  and  patient  then  plan 
for  adequate  care  at  the  time  of  delivery.  In  this  way  the  nurses 
win  and  retain  the  confidence  and  good  wall  of  the  midwives; 
and  since  these  women  exert  a  powerful  influence  over  their 
patients  and  their  families,  their  co-operation  is  of  considerable 
value  in  persuading  the  patients  to  accept  more  skilled  care  than 
midwives  can  offer. 

If,  on  the  other  hand,  the  initial  examination  does  not  dis- 
close any  abnormality,  the  midwife  is  simply  asked  to  allow  the 
nurse  to  visit  the  patient  at  regular  intervals,  in  a  supervisory 
way,  and  to  have  the  patient  report  to  the  clinic  doctor  for  his 
periodic  observations  and  advice.  The  intelligent  midwives, 
w'ho  speak  English,  are  usually  co-operative,  but  the  others  are 
sometimes  suspicious  and  persuade  their  patients  to  refuse  the 
nurse's  supervision. 

For  the  patients  in  the  fourth  group,  those  who  have  made 
no  arrangement  for  care  at  the  time  of  delivery,  the  nurse  is  even 
more  responsible.  The  plans  for  these  patients  include  three 
fundamental  requirements :  a  complete  physical  examination ; 
the  correction  of  physical  defects,  so  far  as  is  possible,  and  a 
study  of  the  environment  and  social  status  of  the  patient;  this 
in  order  to  adapt  the  care  during  pregnancy  and  at  the  time  of 
delivery  to  each  individual's  condition  and  circumstances. 

From  time  to  time  the  nurse  explains  to  the  patient,  as  much 
as  she  can,  about  pregnancy  and  the  changes  that  accompany  it 
and  the  reasons  for  the  advice  that  is  given,  in  order  to  secure 
her  intelligent  co-operation.  Experience  has  taught  that  it  is 
not  enough  to  advise  the  patient  to  do  thus-and-so  because  the 
doctor  thinks  best.  But  if  she  understands  that  examination  of 
her  urine,  for  example,  may  disclose  conditions  that  can  be  cured, 
but  which  if  neglected  may  cause  headaches,  or  convulsions,  she 
is  much  more  likely  to  provide  a  specimen  for  examination  than 
if  she  is  asked  for  one  without  explanation. 


ORGANIZED  PRENATAL  WORK 


415 


The  care  of  each  patient  is  a  tactful  adjustment  of  the  pre- 
scribed routine  to  the  condition,  habits  and  temperament  of  that 
patient.  It  is  carried  on  througli  a  combination  of  visits  which 
the  nurse  makes  to  the  patient's  home  and  visits  which  the  pa- 
tient makes  to  the  nurse  at  the  Maternity  Centre  in  lier  district. 
The  advantagfes  of  this  combination  of  visits  are,  that  the  nurse 
first  knows  the  patient  in  her  own  home,  and  can  help  to  plan 
for  the  desired  care  with  the  conditions  of  this  home  in  mind, 
and  perhaps  evolve  from  tiu'  patient's  simpk^  belongings  the 
equipment  needed  for  lier  earc;  also  tliat  at  the  Centre  it  is 
possible  to  assemble  the  patients  and  give  them  a  certain  amount 


Fig.  144. — Separate  bed  for  the  baby  improvised  from  a  market  basket. 
(By  courtesy  of  the  Maternity  Centre  Association.) 

of  informal  group  instruction.  There  is  at  each  Centre  a  doll 
model  of  a  baby;  a  model  of  a  baby's  bed  (Fig.  144),  showing 
that  a  box  or  a  basket  may  be  used  with  entire  satisfaction ;  a 
model  of  the  mother's  bed,  prepared  for  delivery  at  home  and 
protected  with  newspaper  pads;  a  complete  layette  (Fig.  145) 
to  show  the  mothers  how  simple  such  an  outfit  can  and  should 
be ;  patterns  for  making  each  garment  and  some  one  to  help 
the  women  to  make  them;  a  brea.st  tray  (Fig.  146)  and  a  baby's 
toilet  tray  (Fig.  147),  so  complete  and  yet  so  simple  that  no 
woman  -with  a  few  chipped  or  cracked  cups  to  spare  need  be 
dismayed. 

In  the  course  of  this  group  instruction  the  women  are  taught 
how  to  prepare  for,  and  later  care  for  their  babies.     One  week, 


416 


OBSTETRICAL  NURSING 


the  nurse  demonstrates  to  the  group  how  to  handle  the  baby, 
dressing  and  undressing  or  bathing  it ;  or  explains  the  reason 
for  making  each  article  in  the  model  layette,  or  the  purpose  and 
use  of  each  article  on  the  toilet  tray,  and  shows  them  how  to 
make  boric  acid  solution  and  swabs.  In  short,  each  detail  in 
the  care  of  the  baby  is  gone  over.     Every  alternate  week  the 


^^^^i^^^^^^^Ti^^^vj^^^^ 

■       '-- 

■ 

1  ^x?^ 

■=iF 

^ 

1 A  »1 

£ 

1 

■       II 

■_..^IBI 

■     a     1 

.   H 

1 

Wfil-                          _^^t. 

i 

1 

Fig.  145. — Layette  recommended  to  patients  by  Maternity  Centre  As- 


sociation : 

A.  Flannel  binder. 

B.  Knitted  band  with  straps 


Shirt. 
Petticoat. 


E.  Dress  or  nightgown, 

F.  Diaper. 

Gr.  Pad  for  basket-bed. 
H.  Flannel  square. 


mothers  demonstrate  to  the  nurse.  They  dress  and  undress  the 
doll  model;  explain  and  demonstrate  how  to  make  boric  acid 
solution;  how  to  prepare  sterile  water  and  give  it  to  the  baby. 
Many  of  the  mothers  attend  the  classes  for  several  weeks  in 
succession,  and  frequently  a  mother  returns  with  her  three- 
week-old  baby  to  make  sure  that  she  has  not  forgotten  any  of 
the  details  of  infant  care  which  the  nurse  tyied  to  teach  her 
before  the  baby  came. 


ORGANIZED  PRENATAL  WORK 


417 


A  patient  is  not  asked  to  go  to  the  Centre  for  any  reason  if 
she  seems  very  reluctant  to  go;  or  if  her  going  is  inadvisable 
for  physical  reasons  or  if  it  would  entail  great  hardship,  be- 
cause of  young  children  who  would  have  to  be  taken  with  her,  or 


Fig.  146. — Breast  tray  improvised  from  articles  to  be  found  in  any 
borne,  contains :  Jar  of  cotton  pledgets ;  bottle  of  liquid  petrolatum ;  soap 
on  saucer,  covered  with  cup  for  water  to  bathe  nipples.  (By  courtesy  of  the 
Maternity  Centre  Association.) 

left  at  home  alone.  But  when  they  can  go,  it  simplifies  the  work 
and  enables  each  nurse  to  supervise  a  larger  number  of  patients 
than  if  she  did  all  of  the  traveling  and  visiting. 


Fig.  147. — Baby's  toilet  tray  equipped  with  jelly  glasses,  bottles,  cellu- 
loid hair  receiver  for  cotton,  and  a  soap  dish,  containing: 


1.  Safety   pins   sticking   in  cake          7. 
of  soap.  8. 

2.  Jar  for  sterile  nipples.  9. 

3.  Jar  of  sterile  water.  10. 

4.  Jar  of  boracic  acid  solution.  11. 

5.  Nursing  bottle.  12. 

6.  Sterile  water  to  drink. 

(By  courtesy  of  the  Maternity  Centre  Association.) 


Nursing  bottle  for  water. 
Small  tooth  pick  swabs. 
Liquid  petrolatum. 
Gauze  mouth  swabs. 
Absorbent  cotton. 
Soap. 


418  OBSTETRICAL  NURSING 

Each  patient  is  seen  by  a  doctor  or  a  nurse  every  two  weeks 
until  the  seventh  month  of  pregnancy,  and  once  a  week  after 
the  seventh  month.  At  each  visit  the  nurse  follows  as  much  of 
the  prescribed  routine  as  is  possible ;  this  routine  consists  of 
testing  for  albumen  in  the  urine ;  taking  the  systolic  blood  pres- 
sure ;  listening  to  the  fetal  heart ;  questioning  the  patient  and 
looking  for  the  objective  symptoms  of  complications.  Dur- 
ing these  visits  to  the  homes  the  nurses  are  able  also  to  help 
their  patients  assemble  entirely  satisfactory  outfits  for 
the  care  of  their  nipples,  consisting  perhaps  of  jelly  glasses, 
cheese  jars,  or  handleless  cups.  And  they  help  to  find  a  place 
on  the  shelf  where  this  little  equipment  may  be  kept  undisturbed 
and  always  ready  for  use.  When  it  comes  to  the  measuring  of 
urine,  they  explain  that  the  regular  size  tomato  can  holds  just 
a  quart,  and  is  therefore  quite  as  satisfactory  for  that  purpose 
as  a  costly  graduated  glass  measure. 

No  patient  is  dismissed  for  failure  to  follow  advice ;  the  nurse 
continues  her  visits,  unless  the  patient  positively  refuses  to  admit 
her,  and  she  continues  to  advise,  adjusting  and  modifying  the 
ideal  routine  and  persuading  the  patient  to  do  as  much  as  she 
can,  or  will. 

If  abnormalities  develop  during  pregnancy,  the  nurse  ar- 
ranges for  immediate  medical  care,  either  at  the  patient's  home 
or  in  a  hospital.  If  the  clinic  doctor  feels  that  the  patient  should 
have  hospital  care,  but  she  will  not  or  cannot  go  to  a  hospital, 
she  is  persuaded  to  engage  a  doctor,  and  a  nurse  from  the  Centre 
helps,  as  a  visiting  nurse,  to  take  care  of  the  patient  in  her  own 
home. 

The  next  responsibility  of  the  nurse  is  to  advise  the  patient 
in  arranging  for  care  at  the  time  of  delivery,  this  advice  being 
based  upon  the  patient's  physical  condition,  the  circumstances 
of  her  home  life  and  the  available  facilities  for  care.  Although 
hospital  care  may  be  the  ideal  for  all  patients,  from  an  obstet- 
rical standpoint,  the  mother  cannot  always  be  removed  from 
her  home  with  safety  to  the  family  circle.  Her  physical  and 
social  conditions  therefore  are  considered  together;  if  there  is 
no  complicating  home  problem,  it  is  usual  to  advise  hospital 
care  for  primiparae  and  for  all  patients  who  have,  or  develop 


ORGANIZED  PRENATAL  WORK  419 

abnormalities,  or  have  a  history  of  previous  difficult  labors,  com- 
plications or  abnormalities. 

Patients  who,  the  doctors  think,  give  promise  of  having  com- 
plicated labors  and  who  prefer  to  remain  at  home  are  advised 
to  engage  a  doctor,  and  to  arrange  with  the  Henry  Street  Settle- 
ment for  nursing  care  at  the  time  of  delivery  and  during  the 
puerperium,  as  the  Maternity  Centre  nurses  do  not  perform  this 
service. 

At  one  time,  however,  the  Centre  provided  assistance  to  pa- 
tients delivered  at  home,  in  the  shape  of  a  working  housekeeper 
to  discharge  the  mother's  household  duties  while  she  remained 
in  bed  the  necessary  length  of  time  after  the  baby  was  born,  or 
in  some  cases,  while  she  took  much  needed  rest  during  the  latter 
part  of  pregnancy.  For  this  purpose  the  nurses  had  a  list  of 
women  who  were  good  housekeepers  and  clean  workers  and  whose 
own  children  were  partly  grown.  These  women  were  glad  of 
an  opportunity  to  do  part  time  work  and  earn  a  little  extra 
money.  They  were  paid  thirty  cents  an  hour,  twenty-five 
cents  for  lunch  and  whatever  their  carfare  amounted  to,  the 
patient  paying  whatever  she  could  afford  toward  the  fund,  pro- 
vided by  the  Women's  City  Club,  from  which  these  working 
housekeepers  were  paid.  This  service,  which  in  no  wise  replaced 
the  nurse's  care,  has  been  temporarily  discontinued  because  of 
lack  of  funds,  but  proved  to  be  so  valuable  that  it  will  be  re- 
sumed as  soon  as  possible. 

Supervisory  postnatal  visits  are  paid  to  patients,  not  under 
the  care  of  the  visiting  nurse  service,  who  have  been  under  Ma- 
ternity Centre  Association  care  during  pregnancy,  as  well  as  to 
those  who  have  not  had  this  care  but  are  referred  to  the  Centre, 
by  hospitals,  upon  their  discharge.  The  nurse  first  visits  to 
satisfy  herself  that  the  mother  is  able  to  care  for  her  baby  and 
to  give  any  instructions  that  seem  to  be  necessary.  She  then 
visits  the  patient,  or  the  patient  visits  the  nurse,  when  she  is 
able,  until  the  baby  is  a  month  old,  when  she  is  urged  to  register 
the  baby  at  a  baby  health  station. 

The  importance  and  value  of  birth-registration  is  explained 
to  the  mother  and  the  nurse  endeavors  to  have  a  copy  of  a  birth 
certificate  in  the  mother 's  hands  before  the  case  is  dismissed. 


420  OBSTETRICAL  NURSING 

The  importance  of  post-partum  examinations,  not  later  than 
six  weeks  after  delivery,  is  also  impressed  upon  the  patient. 
Patients  who  are  not  to  be  examined  by  the  doctors  who  de- 
livered them  are  given  a  post-partum  examination  by  a  doctor 
at  the  Maternity  Centre,  to  make  sure  that  they  are  dismissed 
in  good  condition,  or  are  referred  to  the  proper  agency  for  fur- 
ther care,  this  being  the  first  step  in  prenatal  care  for  the  next 
baby. 

Is  all  of  this  elaborate  organization  and  detailed  care  worth 
while  ? 

A  recent  statement  issued  by  the  Maternity  Centre  Associa- 
tion replies  convincingly  that  it  is.  It  says  that  during  1920 
among  women  in  the  Borough  of  Manhattan  not  under  Maternity 
Centre  supervision : 

1.  One  mother  died  for  every  205  babies  born,     (One  out  of  140 
for  the  rest  of  the  country.) 

2.  One  out  of  every  26  babies  born,  died  under  one  month  of  age. 

3.  One  out  of  every  21  babies  was  born  dead. 

Whereas,  among  women  in  Manhattan  who  were  supervised 
by  the  Association,  during  the  same  period: 

1.  One  mother  died  for  every  500  babies  born. 

2.  One  out  of  every  51  babies  born,  died  under  one  month  of  age. 

3.  One  out  of  every  42  babies  was  born  dead. 

The  Association  does  not  usurp  nor  supplant,  but  endeavors 
to  give  impulse  to  public  and  private  agencies  alike  in  affording 
the  best  possible  supervision  and  care  for  expectant  and  par- 
turient mothers  and  their  babies. 

Thus  has  the  stupendous  problem  in  New  York  been  attacked 
with  courage  and  with  gratifying  results.  Much  might  be  accom- 
plished in  smaller  and  less  complex  communities  with  propor- 
tionately less  difficulty. 

But  all  of  the  foregoing  relates  to  city  dwellers.  What  about 
the  expectant  mothers  in  isolated  and  rural  communities? 

I  wish  we  did  not  have  to  say. 

Prenatal  care  is  practically  unknown  among  them  and  there 
is  scarcely  any  provision  for  obstetrical  care,  either.  The  nearest 
physician  may  live  miles  away  and  even  though  one  were  near, 


ORGANIZED  PRENATAL  WORK  421 

country  women  and  their  husbands  do  not  always  feel  that  the 
expense  of  employing  a  doctor,  for  mere  childbirth,  is  justifiable. 

In  certain  Northern  and  Western  communities,  that  were 
considered  fairly  representative  of  those  sections,  conditions 
have  been  studied  at  some  length  by  agents  of  the  Federal  Chil- 
dren's  Bureau.  They  found  that  about  half  of  the  mothers  in 
those  communities  had  no  medical  attention  whatever  in  child- 
birth. Untrained  women,  friends  or  neighbors,  frequently  some- 
one's  grandmother,  were  in  attendance.  Or  husbands  or  work- 
men were  pressed  into  service.  A  few  women  were  entirely  alone 
in  their  hour  of  trial.  Scarcely  a  mother  among  them  received 
prenatal  care  and  instruction  worthy  of  the  name. 

In  the  Southern  states,  the  proportion  of  w'omen  delivered 
by  physicians  seems  to  be  even  smaller  than  in  the  North  and 
West,  and  in  some  of  the  mountain  regions  the  conditions  are 
distressing.  From  one  such  locality  we  learn  that  when  a  woman 
goes  into  labor  the  first  passing  teamster  is  hailed,  or  perhaps 
a  member  of  the  family  hurries  down  the  road  for  the  nearest 
tanner  or  blacksmith,  or  any  one  else,  who  in  total  ignorance 
will  fearlessly  rush  in  to  meet  the  great  emergency.  The  results 
of  this  practice — dismembered  infants  and  badly  injured  or  dead 
mothers, — are  too  sickening  to  describe,  but  may  be  imagined 
by  any  nurse  who  has  seen  good  obstetrical  work  and  appreciates 
its  value. 

From  another  mountain  region  in  the  South  comes  the  con- 
trast in  accounts  of  the  work  done  by  Miss  Lydia  Holman, 
founder  of  the  Holman  Association,  as  evidence  of  what  skill  and 
desire  may  accomplish.  Something  more  than  twenty  years  ago 
this  nurse  started  volunteer  visiting  nursing  among  the  mountain 
people,  with  no  precedent  to  follow  and  no  Board  to  direct  or 
advise.  But  there  were  sick  people  all  about,  people  needing 
care,  and  Miss  Holman  was  not  only  trained  but  eager  to  nurse 
them,  and  after  all  these  qualifications  are  the  chief  requisites. 

After  all  these  years  of  self-sacrificing,  pioneer  work,  of  which 
American  nurses  may  justly  be  proud.  Miss  Holman  has  the 
enviable  satisfaction  of  knowing  that  she  has  lessened  the  perils 
of  childbirth  for  some  600  women  and  saved  practically  all  of 
their   babies.    Much   of   this   in   the    simplest,    most    meagerly 


422  OBSTETRICAL  NURSING 

equipped  mountain  homes.  She  has  even  managed  to  have 
some  of  the  mothers  taken  to  a  nearby  town  for  the  repair  of 
lacerations  which  occurred  during  labor.  And  she  has  a  little 
hospital  now  up  on  the  mountain  top,  with  doctors  and  nurses, 
not  only  caring  for  sick  people,  but,  among  other  things,  teaching 
women  and  girls  how  to  care  for  infants  and  children, 

A  complete  maternity  service  for  rural  communities  would 
evidently  include  small  hospitals  for  primiparas  and  abnormal 
cases  and  to  serve  as  centres  from  which  nurses  and  doctors 
would  carry  on  prenatal  supervision  and  instruction,  and  give 
skilled  attention  at  birth;  followed  by  visiting  nursing  of  the 
young  mother  and  her  baby.  The  prenatal  supervision  in 
sparsely  settled  districts  might  leave  much  to  be  desired,  be- 
cause of  the  impossibility  of  seeing  each  patient  as  often  as  is 
wise.  But  even  a  little  care  would  be  an  improvement  upon 
present  conditions.  In  some  localities,  it  has  been  found  possible 
to  teach  some  of  the  more  intelligent  of  these  rural  mothers  a 
good  deal  about  their  own  supervision.  One  nurse  tells  of  a  very 
isolated  woman  who  could  only  be  visited  at  long  intervals  whom 
she  taught  to  test  her  own  urine  for  albumen,  explaining  its  pos- 
sible significance  and  seriousness.  One  day  the  report  card  that 
came  by  mail  indicated  that  the  last  test  showed  albumen.  But 
the  card  also  carried  the  remark,  *' Don't  worry  about  this,  I 
am  drinking  lots  of  water,  taking  nothing  but  milk  for  food  and 
will  be  in  to  see  the  doctor  on  Tuesday, ' ' 

This  hints  at  some  of  the  possible  adjustments  that  must  be 
made  in  meeting  the  needs  of  the  patient  in  unusual  circum- 
stances. For  we  are  constantly  facing  the  unalterable  fact,  that 
no  matter  where  she  is,  nor  what  conditions  surround  her,  the 
individual  woman  needs  care  and  supervision,  and  though  con- 
ditions vary,  the  general  needs  of  expectant  mothers  are  the 
same. 

This  survey  of  the  situation  in  cities  and  rural  communities 
gives  us  a  glimpse  of  what  can  be  done  about  it — this  problem 
of  mothers  and  babies  who  need  care — and  also  what  is  being 
done,  and  we  begin  to  sense  an  answer  to  the  question,  "Is  any- 
thing more  possible?" 

It  is  clear  that  a  wide  extension  of  provisions  for  prenatal 


ORGANIZED  PRENATAL  WORK  423 

care  is  necessary  if  all  mothers  are  to  be  reached;  rich,  middle- 
class  and  poor;  in  cities,  small  towns  and  rural  districts  alike. 
We  believe  that  it  is  possible;  and  we  are  sure  that  wherever 
provision  for  prenatal  care  is  made,  the  achievement  of  its  fine 
purpose  will  depend  very  largely  upon  the  spirit  of  the  indi- 
vidual nurse. 

What  does  it  bring  to  the  individual  nurse — this  survey  of 
the  problem  as  a  whole,  with  the  suggestion  for  its  possible  solu- 
tion? The  appeal  of  not  a  few  mothers  and  babies,  only,  but 
of  a  legion,  and  of  uncounted  homes  and  family  circles  in  danger 
of  being  broken.  And  it  l)rings  a  suggestion  of  the  immeasur- 
able comfort  and  influence  which  the  maternity  nurse  may  carry 
into  each  home  that  she  enters.  For  she  helps  to  save  lives  and 
health,  and  through  them,  homes  and  family  groups,  and  these 
are  the  building  blocks  of  the  nation. 

For  the  nurse  whose  imagination  is  touched  by  this  appeal, 
it  will  exact  much — the  best  and  most  that  she  has  to  give — 
but  in  return  she  will  find  a  deep  and  enduring  satisfaction  in 
her  work. 

FORMS  AND  ROUTINES  USED  BY  MATERNITY  CENTRE 
ASSOCIATION,  N.  Y.  C. 

ROUTINE   FOR   PRENATAL   VISITS: 

First  Visit. — Get  acquainted  with  the  patient  and  get  her  confidence. 
Learn  if  she  has  made  any  arrangements  for  her  care  at  time  of  de- 
livery. If  a  doctor  or  midwife  has  been  engaged  commnnieate  with 
him  or  her.  If  the  patient  is  registered  with  a  hosi:)ital,  or  is  nnder 
other  nursing  care,  note  that  on  your  record,  also  on  slip  sent  to 
Central  Office.  Always  ask  to  see  patient's  hospital  or  clinic  card, 
or  any  card  which  she  may  have  been  given  by  any  nurse  or  other 
visitor.    Give  patient  pink  card. 

Explain  simply  the  reason  for  an  expectant  mother  seeing  a  doctor 
and  nurse  early  and  regularly.  Invite  the  patient  to  come  to  the  Center. 
Ask  her  in  a  general  waj^  about  herself,  when  the  baby  is  expected, 
other  pregnancies  and  deliveries,  and  illnesses;  other  members  of  her 
family.  Direct  your  conversation  so  as  to  get  as  much  data  as  possible 
without  asking  a  direct  cjuestion.  Do  not  attempt  a  full  nursing  visit 
unless  the  patient  meets  you  more  than  half  way.  Every  patient  is  to 
be  encouraged  to  come  to  the  Center  for  as  much  of  the  nursing  care 
as  is  possible  for  that  individual  woman.  In  the  care  of  all  patients  it 
is  the  nurse's  responsibility  to  make  every  effort  to  solve  (by  working 


42€  OBSTETRICAL  NURSING 

with  every  existing  agency)   such  home  problems  as  might  effect  the 
health  of  the  mother  or  baby  or  disturb  the  mother's  peace  of  mind. 

Comjilete  Nursing  Visit. — Ask  the  patient  about  any  aches,  pains, 
troubles  of  any  kind,  directing  your  questions  to  cover  all  items  on 
record.  Select  a  table,  chair,  machine  top,  or  end  of  mantel,  to  use 
as  work  table,  and  place  on  it: 

Newspaper  for  protection 

Paper  napkin  as  cover  Bottle  for  specimen  or 

Nurse's    soap,    hand    scrub    and 

towel  fTest  tube  and  holder 

Watch 

Fountai  i  pen 
Maternity  Record 
Thermometer 
Tycos 


Urinometer 
Litmus  paper 
Acetic  Acid — 2% 
Sterno 
.  Matches 


Take  temperature,  pulse,  respirations  and  blood  pressure  (to  take 
blood  pressure  adjust  sleeve,  get  radial  pulse,  pump  until  obliterated, 
let  out  air  and  read  dial  at  moment  pulse  returns.  See  Tycos  Manual, 
sample  No.  2,  for  full  detail.)  Wash  thermometer  thoroughly  with 
soap  and  water,  dry  and  return  to  case.  Scrub  hands.  Inspect  or 
demonstrate  the  care  of  nipples ;  to  be  done  daily  after  the  fifth  month, 
not  before.  Use  cotton  ball  (or  soft  toothbrush  previously  scalded 
and  kept  for  this  purpose).  Thoroughly  scrub  each  nipple  with  warm 
water  and  white  soap  and  dry  with  a  clean  towel.  Apply  albolene, 
pulling  out  the  nipple.  Do  not  handle  breasts.  Listen  to  the  fetal 
heart.  If  unable  to  hear  make  note  on  record  n.h.  If  fetal  movements 
are  felt  by  nurse  put  an  "x";  if  patient  says  she  feels  the  baby  move, 
put  "xx"  in  space  on  record  for  recording  fetal  heart  rate.  Look  for 
edema,  varicose  veins;  do  not  take  the  patient's  word  for  these  symp- 
toms. Apply  bandage  for  varicose  veins  (patient  to  pay  70  cents  for 
bandage,  or  bandage  to  be  lent  to  patient  as  long  as  needed,  to  be 
washed  and  returned),  and  teach  patient  right-angle  position.  Get 
specimen  of  urine,  either  to  take  to  the  station  for  examination  or  to 
examine  at  once  for  specific  gravity,  reaction  and  albumen,  in  accord- 
ance with  instruction  given  on'  page  30,  Laboratory  Technique — Wood, 
Vogel  and  Famulener.  Have  the  patient  cleanse  vulva  before  voiding, 
and  void  in  clean  vessel.  Teach  patient  proper  disposal  of  urine, 
emphasizing  why  kitchen  sink  is  not  to  be  used.  If  any  abnormality 
in  amount,  color,  specific  gravity,  or  trace  of  albumen,  report  to  the 
doctor,  midwife  or  hospital  in  charge  of  the  patient,  if  the  patient  has 
engaged  one;  if  not,  use  every  effort  to  get  the  patient  under  care  of 
doctor. 

Teach  patient  to  measure  amount  of  urine  voided  in  24  hours.  Tell 
her  to  void  in  toilet  on  getting  up  in  A.M.;  then  for  the  rest  of  that 
day  and  night  and  the  following  A.M.  to  void  in  a  suitable  vessel  and 
measure  in  a  tomato  can  (if  no  suitable  vessel,  void  in  a  tomato  can) 
and  keep  count  of  how  many  times  she  fiJls  the  can. 


ORGANIZED  PRENATAL  WORK  425 

On  an  early  visit  examine  teeth  and  show  how  to  keep  clean.  Where 
possible  urge  a  visit  to  the  dentist  or  dental  clinic  for  prophj'lactic  treat- 
ment. Explain  that  it  is  not  wise  to  have  extractions  done  during 
pregnancy  without  consulting  a  doctor,  but  that  cleansing  and  tem- 
porary fillings  may  be  done  with  much  saving  of  teeth. 

On  one  visit,  as  early  as  possible,  ask  to  see  the  layette,  and  advise 
about  it,  going  over  the  list  of  baby  supplies.  Urge  the  patient  to 
visit  the  center  to  see  the  model  layette,  and  get  help  in  the  choice  of 
materials  and  patterns.  Note  on  the  record  if  layette  is  not  complete  by 
the  eighth  month.  Demonstrate  the  preparation  of  bed  for  the  baby, 
made  from  clothes  basket,  soap  box,  or  in  a  baby  carriage  similar 
to  the  model  at  the  center.  If  the  patient  is  to  be  delivered  at  home, 
some  time  after  the  seventh  month  ask  to  see  the  mother's  supplies, 
going  over  the  list.  The  patient  should  be  advised  against  the  use  of 
oilcloth  from  the  kitchen  table  as  a  bed  protector,  and  especially  urged 
to  prepare  newspaper  pads  like  the  model  at  the  center.  Note  on  the 
report  if  the  mother's  supplies  are  not  complete  by  the  eighth  month. 
Advise  about  the  arrangement  of  the  room  for  delivery,  and  demon- 
strate the  preparation  of  the  mother's  bed  like  the  model  at  the  center. 

No  treatment  or  medicine  to  be  advised  except  in  accordance  with 
standing  orders,  private  physician's  orders,  hospital  orders  and  Ma- 
ternity Centre  Association  routine  (note  on  record  which). 

Form  letter  signed  by  the  head  of  the  medical  board  sent  to 
doctors  who  have  been  engaged  by  patients  for  delivery: 

My  dear  Dr : 

Mrs who  has  engaged  you  for  her 

care  at  delivery,  has  been  referred  to  this  association  for  nursing  care. 

In  order  to  make  the  work  of  the  nurses  of  this  association  of  a 
uniformly  high  standard,  the  Medical  Board  has  adopted  the  enclosed 
routine  for  the  nurses  to  follow. 

May  we  not  have  your  cooperation  in  our  effort  to  teach  the  women 
of  the  community  the  need  for,  and  value  of,  medical  supervision 
throughout  their  pregnancy? 

May  we  have  your  permission  to  instruct  our  nurses  to  visit  Mrs. 
in  accordance  with  our  routine,  and  re- 
port each  visit  to  you? 

A  prompt  reply  on  the  enclosed  slip  will  be  greatly  appreciated. 

Cordially  yours, 


426  OBSTETRICAL  NURSING 


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ORGANIZED  PRENATAL  WORK  427 

MATERNITY  RECORD 

The  Maternity  Record  upon  which  a  complete  histoiy  of  each  case 
is  recorded  is  divided  into  four  parts,  the  first  section  for  the  social  data 
about  the  patient,  the  second  for  other  pregnancies  and  observation  of 
patient  during-  this  pregnancy,  the  third  records  deliveiy  and  post- 
partum care,  the  fourth,  post-natal  care.     (See  insert  for  form.) 

LEAFLET   OF  INSTRUCTIONS   GIVEN  TO  PATIENTS 

ADVICE  FOR  MOTHERS 

Motherhood  is  natural  and  normal.  If  you  do  as  the  doctor  and 
nurse  ask  you  to,  you  have  no  reason  to  worry  about  having  your  baby. 

DIET 

Eat  the  food  you  are  used  to.  Do  not  eat  what  you  know  gives  you 
indigestion.     Do  not  eat  too  much  at  any  one  meal. 

Drink  8  glasses  of  water  every  day. 

Drink  all  the  milk  you  can. 

Do  not  drink  any  beer,  whiskey,  wine  or  other  alcohol.  These  hurt 
the  kidneys  and  thus  may  poison  the  baby. 

Eat  meat,  meat-soup  or  eggs  and  drink  tea  or  coffee  only  once  a  day. 

SLEEP 
At  least  8  hours  eveiy  night  with  windows  open. 

EXERCISE 

Do  your  regular  house  work,  but  lie  down  several  times  a  day_  if 
only  for  five  minutes.  If  possible  take  a  walk  out  of  doors.  Fresh  air 
is  good  for  your  baby.  If  you  cannot  get  out,  keep  the  windows  open 
while  3'ou  work  indoors.     Do  not  do  heavy  work ;  it  will  hurt  your  baby. 

BATHING 
Wash  all  over  every  day  with  warm   (not  hot)  water,  but  do  not 
get  into  a  tub  after  the  seventh  month. 

GARTERS 
Do  not  wear  round  garters  or  any  tight  bands.     The  nurse  will  show 
you  how  to  make  suspender  garters. 

CONSTIPATION 

If  you  are  constipated,  drink  a  cup  of  coffee  (no  cream  or  sugar) 
before  breakfast,  hot  milk  (not  boiled)  with  breakfast,  go  to  the  toilet 
at  the  same  time  every  day  (after  breakfast  best).  During  the  day 
eat  coarse  bread,  green  vegetables,  stewed  fruit,  drink  no  tea,  but  all 
the  water  you  can,  at  least  8  glasses,  hot  or  cold.  Cook  2  tablespoonfuls 
of  senna  leaves  with  a  pound  of  prunes  and  eat  four  to  six  prunes 
every  day.     If  you  have  hemorrhoids  (piles)  hold  a  cold  compress  to 


428  OBSTETRICAL  NURSING 

anus  for  five  minutes  after  bowels  move  and  do  not  let  yourself  get 
constipated.  Never  take  any  cathartics  unless  your  doctor,  midwife,  or 
nurse  tells  you  to. 

IMPOST  ANT 

Do  not  have  any  sexual  intercourse  after  the  8th  month.  If  you 
have  severe  headache,  vomiting,  spots  before  your  eyes,  if  your  face, 
hands  or  feet  swell,  let  your  hospital,  doctor  or  midwife  and  nurse 
know  at  once. 

Labor  begins  with  pains  in  back  or  abdomen;  with  bleeding  or 
watery  discharge.  If  you  have  any  labor  pains  or  bleeding  before 
the  time  you  expect  your  baby,  go  to  bed  and  send  word  to  your  hos- 
pital, doctor  or  midwife  and  nui'se  at  once. 

If  you  are  going  to  the  hospital,  have  ready  after  the  8th  month 
one  set  of  baby  clothes,  to  take  with  you  to  put  on  the  baby  when  you 
bring  him  home.  Do  not  take  anything  else  with  you,  the  hospital  will 
supply  all  you  need.     As  soon  as  labor  begins,  go  to  the  hospital. 

If  you  are  to  be  confined  at  home,  as  soon  as  labor  begins  send  for 
the  doctor  or  midwife.  If  the  doctor  is  one  of  the  hospital  doctors, 
follow  the  directions  on  your  card  from  the  clinic. 

While  waiting  for  the  doctor,  boil  a  large  quantity  of  water  in  a 
covered  vessel  and  set  aside  to  cool.  Prepare  your  bed  as  the  nurse 
has  shown  you,  take  a  warm  sponge  bath,  braid  your  hair  in  two  braids, 
get  out  a  set  of  baby  clothes  ready  for  the  nurse  to  dress  the  baby. 
Get  out  supplies  needed  for  yourself. 

mother's  supplies 

2  gowns.  Cotton   (absorbent). 

1  pair  white  stockings.  2  wash-cloths. 

4  sheets.  2  towels. 

6  bed  pads.  4  oz.  lysol. 

Vulva  pads  or  supply  of  freshly  1  bedpan, 
laundered  old  muslin. 

The  bed  pads  are  made  from  6  thicknesses  of  newspaper  open  to 
full  size  and  covered  with  freshly  laundered  old  muslin  tacked  in  place. 
No  other  protection  for  bed  is  necessary.  As  a  precaution,  when  possi- 
ble, the  entire  mattress  may  be  covered  with  oilcloth  put  on  under  the 
bottom  sheet.  See  model  at  center.  All  washable  supplies  for  mother 
and  baby  should  be  freshly  laundered  and  put  away  in  pillowcases  or 
clean,  ironed  paper  until  they  are  needed. 

baby's  supplies 

The  following  is  a  list  of  the  complete  outfit  of  baby  clothes  and 
toilet  necessities.  It  may  be  modified  as  to  material,  quantity  and 
quality  to  suit  the  individual  taste  and  pocketbook. 


ORGANIZED  PRENATAL  WORK  429 

12  Diapers  18"  x  18".  1  Felt  pad  or  folded  blanket  for 

3  Bands  6"  x  27".  mattress. 

3  Shirts,  size  2,  cotton  and  wool        i  oilcloth  case  for  mattress. 

3  Petticoats.  2  Muslin    pillow-cases    for  mat- 
3  Slips.  ^^^gg 

2  Squares   36"  x  36". 

Note:  The  squares  are  used  in-  2  Crib  blankets,  small  size. 

stead    of    coat    and    bonnet  '-  Towels. 

until  the  baby  is  more  than  2  Wash-cloths,     old     pieces     of 

2  months  old.     See  model  at  linen. 

the  center.  ^^  piece  Castile  soap. 

1  Oilcloth  or  rubber  12"  x  18".  „         ,      .        . ,  , 

_„  ,  „  .  8  oz.  bone  acid  powder, 

12  large  safety  pms. 

12  small  safety  pins.  ^  P^^^^^^  absorbent  cotton. 

1  Basket  or  box  for  bed  15"  x  1  Q^art  oil— sweet  or  albolene. 

30".  1  package  toothpicks. 

Tray— fitted  with: 

Glass  jar  for  boric  acid  solution. 

"       "       "   nipple  swabs. 

"       "      "    oil. 

"       "      "    small  toothpick  swabs. 
Dish  for  soap. 

Cake  of  soap  to  stick  pins  in  instead  of  a  pin  cushion. 
Hair  receiver  for  absorbent  cotton. 
Newspaper  cornucopias  for  waste. 
Bottle  and  nipple  for  giving  baby  water. 
Covered  pail  with  borax  water  for  soiled  diapers. 
Jars  for  tray  may  be  empty  cheese,  candy  or  jelly  jars. 

CLINIC  ROUTINE 

The  nurse  is  urged  so  to  conduct  her  clinic  as  to  assure  privacy  to 
each  patient  examined,  and  the  same  treatment  which  the  patient  would 
receive  if  she  were  the  only  patient  in  the  office  of  one  of  our  best 
obstetricians. 

Nurse  is  to  wear  her  graduate  uniform  during  clinic  and  during  her 
office  hours. 

Nurse's  Duties 

1 — Preparation  of  Clinic  Room 

Pads  of  doctor's  record,  return  visit  to  doctor,  post-partum  examina- 
tion; pencil;  examining  table;  side  tables;  sterilizers;  basins;  instru- 
ments; supply  of  clean  dry  gloves;  Dejiartment  of  Health  material  for 
taking  Wassermanns,  cultures  and  smears;  cotton  balls;  tampons; 
throat  sticks;  sheets;  pillow  cases;  sounding  towel;  adequate  supply 


430  OBSTETRICAL  NURSING 

of  clinic  drugs;  solutions;  thermometer,  in  glass  of  50  per  cent  alcohol; 
glass  of  ootton ;  to  be  ready  one-half  hour  before  the  time  set  for  clinic. 

2 — Preparation  of  Patients'   Dressing  Room 

Screens  or  curtains  arranged  to  form  individual  dressing  rooms ;  a 
sufficient  number  of  clean  clinic  gowns;  separate  chair  provided  for 
each  patient  to  leave  clothes  on,  unless  room  is  provided  with  racks  or 
hooks. 

3 — Preparation  for  Urinalysis 

Unless  the  urinalysis  is  made  so  near  the  toilet  that  the  waste  urine 
may  be  thrown  directly  into  the  toilet,  a  covered  pail  is  to  be  provided 
one-fourth  full  of  1  per  cent  lysol  solution.  All  waste  urine  and  wash- 
ings from  the  test  tubes  to  be  thrown  into  this  pail,  and  under  no  circum- 
stances is  waste  urine  to  be  thrown  into  any  sink  or  wash  basin,  even 
though  the  basin  is  not  used  as  a  wash  basin. 

Test  tubes,  stemo,  litmus,  acetic  acid,  funnel,  filter  paper,  test  tube 
holder,  vessel  for  collecting  specimen,  basin  of  1  per  cent  lysol  solution 
and  cotton  balls  for  patient  to  cleanse  vulva  before  voiding,  basin  for 
used  cotton  balls,  pi'OAasion  for  patient  to  wash  hands,  to  be  in  readi- 
ness one-half  hour  before  the  time  set  for  clinic. 

4 — Preparation  of  the  Patient  for  Examination 

Each  patient  to  completely  undress,  except  her  shoes  and  stockings, 
and  to  put  on  clean  gown  supplied  by  the  clinic.  Her  shoes  to  be 
unfastened  so  that  the  doctor  can  examine  her  ankles  for  edema,  her 
temperature  to  be  taken  and  a  urinalysis  made  before  the  patient  is 
seen  by  the  doctor. 

5 — Assisting  Doctor  in  Examining  Room 

Make  notes  on  record  pad  at  the  doctor's  dictation,  reminding  her 
tactfully  of  anjf  omissions  made  in  her  dictation.  Conduct  examina- 
tion in  the  following  order :  Head,  chest,  breasts,  blood  pressure,  abdom- 
inal, fetal  heart,  measurements,  ankles,  vaginal,  Wasseitnanns  or 
smears  when  necessary. 

Note:  Preparation  for  vaginal  examination.  Sponge  vulva  with 
1  per  cent  lysol  solution.    Give  doctor  fresh  gloves  for  each  patient. 

The  nurse  is  responsible  for  the  technique  in  the  clinic  room,  not 
the  doctor. 

If  the  doctor  wishes  to  do  a  vaginal  examination  on  a  patient  more 
than  eight  months  pregnant,  or  one  who  is  bleeding,  take  same  precau- 
tion as  though  examining  a  patient  in  labor ;  clip ;  scrub  with  green  soap 
and  water;  then  1  per  cent  lysol;  give  doctor  freshly  boiled,  sterile 
gloves. 

6 — Arrangement  of  Examining  Room  After  Clinic 

Soiled  linen  in  laundry  bags;  fresh  linen  on  tables,  tables  covered; 
all  used  instruments  to  be  washed,  scrubbed  when  necessary,  boiled  five 


ORGANIZED  PRENATAL  WORK       431 

minutes,  dried  and  put  away;  all  gloves  used  to  be  washed  in  cool 
water  and  j^ieen  suap  and  thoroughly  rinsed,  wrapped  in  towel,  dropi)ed 
.in  boiling  water  and  boiled  for  five  minutes,  then  dried,  powdered  and 
put  away  in  a  dean  towel  ready  for  use  at  next  clinic;  solution  basins 
to  be  emptied,  washed  and  dried;  all  waste  to  be  seciirely  rolled  up  in 
newspaper  and  put  in  a  house  garbage  can;  supply  of  drugs  to  be 
cheeked  up  and  replenished  when  necessary. 

7 — Records 

All  "Doctor's  Record"  cards  to  be  written  up  and  filed;  reports 
mailed  to  the  central  ollice;  reports  on  the  condition  of  patient  sent  to 
nursing  agencies  caring  for  the  patient  and  other  agencies  working  on 
the  case;  maternity  records  to  be  tiled  in  date  file  before  the  nurse  goes 
off  duty. 

Doctor's  Duties  as  Outlined  on  Doctor's  Record 

1.  One  complete  physical  examination  including  heart,  lungs, 
breast,  blood  pressure,  abdominal  examination,  fetal  heart,  pelvic 
measurements,  vaginal  examination  and  a  Wassermann  and  G.  C. 
smear  on  all  patients  Avith  a  suspicious  history.  Notes  on  this 
examination  to  be  dictated  to  the  nurse. 

2.  Blood  pressure;  abdominal;  urinalysis;  on  return  visits  and  pro- 
vides space  for  notes  on  such  other  observations  as  she  may  wish 
to  make. 

3.  One  post-partum  examination  on  every  patient ;  including  a 
statement  on  general  condition;  examination  of  breasts;  vaginal; 
uterus;  perineum;  and  note  results  of  any  intercurrent  dis- 
ease. 

4.  Eecording  advice  given  to  patient. 

5.  Instructing  patients  when  to  return  to  see  the  doctor.  Note: 
All  patients  not  registered  with  a  hospital  or  private  doctor,  to 
be  seen  by  the  clinic  doctor  once  a  month  up  to  the  seventh 
month,  and  once  in  two  weeks,  or  oftener  as  the  case  demands, 
thereafter. 

8 — Duties  of   Clinic  Assistants 

At  those  clinics  where  a  lay  woman  acts  as  assistant  to  the  nurse, 
the  following  duties  (and  no  others  without  special  permission)  may 
be  assigned  to  the  assistant : 

1.  Greeting  patient;  and  from  name  on  her  pink  card,  getting 
her  maternity  record  from  file  and  sending  to  nurse. 

2.  Taking  temperature,  a  record  of  which  is  sent  in  to  the  nurse 
on  a  scratch  pad  and  copied  by  her  on  her  clinic  record. 

3.  Urinalysis. 

4.  Helping  patient  dress  and  undress. 

5.  Care  of  any  children  who  maj*  come  with  patient. 


432 


OBSTETRICAL  NURSING 


6.     See  that  patient  understands  when  to  return  and  has  her  pink 
card  so  marked  before  she  leaves. 


CLINIC   EQUIPMENT   STANDARD 

Requirements: 

Room  for  examining,  and  dressing  room,  screens,  running  water, 
gas,  near  a  toilet,  urinalysis  facilities,  good  light, 


Chair   

Desk 

Blotting  pad 

Blotter    

Ink-well    . .  . , 


1 

1 

1 

1 

1 

Penholder 2 

Office: 

Clips 

Ruler    1 

Waste  basket    2 

Hand  blotters   12 

Ink,  Red  and  Black 

Charities  Directory 1 

Examining  Room: 

Table  1 

Pad  1 

Pillow  1 

Foot  bench    1 

Shelves  or  side  table  for  sup- 
plies, etc 1  set 

Garbage  pail  1 

Pelvimeter    1 

Tape  measure  1 

Stethoscope 1 

Tenaculum  1 

Scissors 1 

Bivalve  speculum  1 

Uterine  Dressing  Forceps. ...  1 
Blood  Pressure  machine 

(Tycos)    1 

Thermometers    3 

Thermometer    Glasses    (1    for 

cotton)    2 

Enamel  jars  for  tampons  and 

pledgets    2 

Large  basin  1 

Small  basin   1 

Erlemeyer     flasks     for     green 

soap  and   lysol    2 

Medicine  Glass   1 

Hand  Scrub 2 

Rubber  gloves,  No.  71/2 6  pr. 

Absorbent   cotton    1  lb. 

String   Iball 


Pens, 
Erasers, 

Ink 

Pencil    

Red  Pencil  . . , 
Rubber  bands 


Map    of   Manhattan    in    Sani- 
tary areas    1 

Report  on  vital  statistics 1 

Babies'  Welfare  directory ....  1 
Guide  Cards  Baby  Health 

Station   1 


Spatulee 100 

Hemoglobinometer    (Tahl- 

quist)    1 

Needles   (skin) 

Wassermann  Set  from  D.  of  H.  1 
G.  C.  Smear  Set  from  D,  of  H.  1 
Culture  tubes  from  D.  of  H. 

Bandages  (Ace)   6 

Sterilizer 1 

Sterilizer  burner 1 

Metal  Shelf  or  table  for  Gas 
sterilizer 

Scott  Tissue  Towels 6 

Urinalysis  outfit   1 

Test  tube  rack   1 

Test   Tubes    12 

Test  Tube  holder 1 

Urinometer    1 

Sterno 
Matches 

Enamel   Measure    1 

Dish  (Chamber)   1 

Litmus 

Acetic  Acid  2% 

Toilet  paper 

Funnel    1 

Filter  paper 
Covered  pail 


ORGANIZED  PRENATAL  WORK 


433 


Linen: 

Sounding   towels    (for   use   in 

listening  to  F.  H.) 6 

Sheets    6 

Pillow  cases    3 

Doctor's  gowns  2 

Sewing  Bag: 
Cotton  70 
Cotton  30 
Needles,  assorted 
Thimble 

Drugs: 
K  Y 

Lysol 

Green  soap 
Boro  Glj'cerin 

Breast  Tray: 

Castile  soap  in  dish 
Small  bowl 
Bottle  of  albolene 


Dusters 

Gowns  for  patients. 
Covers  for  tables. . 

Laundry  bags   

Towels    


.     6 

,  12 

•a-s. 

2 
.     6 


Tape  measure 
Tape 

Safety  Pins 
Plain  Pins 


Alcohol 

lodin 

Albolene 


Jar  of  cotton  balls 
Soft  toothbrush 


Exhibit  on  Table: 

Patterns  for  baby  clothes. 

Complete  layette.     Slip  and  petticoat  open  in  back. 

Basket  for  baby  bed. 

Pad  (of  felt  or  hair  mattress). 

Rubber. 

Pillow  cases. 

Blanket  (crib). 

Doll  (baby)  dressed. 

Suspender  garter  for  mother — abdominal  support  with  garters. 

Patient's  bed  prepared  for  time  of  delivery,  newspaper  pads. 

Toilet  Tray: 

Jar  of  boiled  water  (for  washing  mother's  nipples). 

Jar  of  oil   (mineral  oil  best). 

Jar  of  boric  acid— 2%  for  baby's  eyes. 

Jar  of  breast  swabs. 

Jar  of  small  swabs. 

Absorbent  cotton  in  container  (hair  receiver). 

Soap  in  dish. 

Soa]>  with  safety  pins,  instead  of  pincushion.. 

Jar  for  clean  nipples. 

Bottle  and  nipple,  or  cup  and  spoon  for  giving  baby  water. 

Bottle  of  boiled  water  (day's  supply  boiled  fresh  each  day)   and 

kept  corked. 
Newspaper  cornucopia  for  waste. 


434 


OBSTETRICAL  NURSING 


Contents  of  Nurse's  Bag: 

Any  nurse  may  remove  from  her  bag  any  article  not  necessary  in 
her  district  or  for  any  one  day's  work,  provided  she  makes  note  of 
same  on  card,  which  is  left  in  bag  pocket,  stating  where  removed 
articles  may  be  found. 


1  mouth  thermometer 

1  Babies'  Welfare  Directory 

1  rectal            " 

1  Board  of  Health  Station  card 

1  baby  scale 

1  Sounding  towel  in  envelope 

Acetic  acid — 2% 

1  abs.  cotton  in  envelope 

1  test  tube 

1  scratch  pad 

1  test  tube  holder 

Addressed  postals 

1  test  tube  brush 

Advice  to  mothers 

1  blue  litmus 

Letterhead   memo  pad  and  enve- 

1 urinometer 

lopes 

1  sterno 

Pink  cards 

1  matches 

Maternity  Records  for  patients  to 

2  specimen  bottles 

be  visited 

Paper  napkins 

Blank  Maternity  Records 

Soap  and  hand  scrub  in  bag 

Prudential  Ins.  Co.  Baby  Primer 

1  flashlight 

1  Tycos  Blood  Pressure  apparatus 

1  fountain  pen 

3  Ace  Bandages 

1  Street  directory 

MATERNITY   CENTRE   STANDING   ORDERS   FOR  NURSES 

These  standing  orders  may  be  used  at  the  discretion  of  the  nurses 
when  a  patient  is  under  no  other  medical  supervision.     When  patients 
are  registered  with  a  midwife,  may  be  used  with  her  consent. 
Ante-Partum  Orders 


Cathartic ; 


Heart  Burn; 

Binder: 
Brassiere : 

Toxemia : 


After  hygiene,  diet,  prunes  and  senna  have 
failed,  use  either 

Caseara,  grains  5,  or, 

Licorice  Powder,  beginning  with  drams  2  and 
reducing  dose  gradually. 

For  neglected  constipation  use  one-half  pint 
warm  oil  (sweet  oil,  albolene  or  olive  oil) 
enema,  followed  in  one-half  hour  by  soap 
suds  enema  (this  treatment  to  be  given  by 
the  nurse). 

After  advice  as  to  diet,  water,  habits,  constipa- 
tion, use  Soda  Bicarbonate  tablet,  grains  10 
(do  not  ad^dse  or  allow  Baking  Soda). 

Abdominal  binder  like  pattern  P.R.N,  for  l>eavy 
abdomen,  backache. 

Brassiere  for  breast  support  P.R.N.  (Debevoise 
tape  best  if  patient  can  afford;  if  cannot 
afford  have  patient  make  one  like  sample 
support  at  Center). 

Until  medical  attention  can  be  secured  ad^^se: 
1.  Mild — as    much    rest    as    possible;    force 
water  8  to  10  glasses  a  day. 
Diet — milk,     cereals,     vegetables,     stewed 
fruits  and  oranges   (no  jieas  or  beans). 
Eliminate  all  salt  and  condiments. 


ORGANIZED  PRENATAL  WORK 


435 


Post-Partum  Orders: 
Breasts : 


Post-Natal  Orders: 

Thrush : 

Constipation : 
Cireumoision : 
Excoriated  Buttocks: 
Oozing  Umbilicus : 
Protruding  Umbilicus : 


Severe — patient   in   bed.     No   vegetables; 

diet  of  milk  and  cereals  only. 
With    edema.      Reduce    water   to    3    or   4 

glasses  for  three  days,  after  that  force 

water  and  follow  2. 


For  all  cases  instruct  mothers  to  leave  breasts 
alone,  no  pumping,  no  massage.  Supporting 
binder  P.R.N,    (brassiere  best). 

For  engorgement,  follow  preceding,  and  re- 
strict so-called  milk-making  foods,  but  not 
water.  To  dry  up  milk,  follow  preceding  and 
advise  sodium  phosphate  daily  in  frequent 
small  doses  (about  drams  1). 

For  cracked  nipples,  apply  paste  of  Bismiith 
Subnitrate  and  Castor  Oil,  equal  parts  each. 
Use  nipple  shield.  If  not  healed  report  to 
Central  Office. 

Cathartic,  Cascara  axains  5,  or  mineral  oil  1/2 
dram,  or  licorice  powder  drams  2.  For 
neglected  constipation,  use  enema  as  described 
for  ante-partum  patients. 


Solution  of  Soda  Bicarbonate  (1  tablespoonful 
to  1  glass  of  water)  ;  apply  to  spots  with 
swab  before  and  after  nursing.  If  not  effec- 
tive send  baby  to  dispensary  or  doctor. 

Olive  Oil  and  Glycerin,  equal  parts  of  each, 
minims  5-15  to  dose. 

If  penis  is  not  thoroughly  healed,  dress  with' 
Aristol  powder. 

Castor  Oil  and  Bismuth  Paste,  equal  parts  of 
each. 

Cleanse  with  alcohol  on  swab,  dust  with  Aristol 
powder,  apply  dry  sterile  dressing. 

If  dry,  strap  with  well  covered  button  or  coin, 
using  wide  adhesive  tape. 


ROUTINE    FOR    POST-NATAL    FOLLOW    UP 

Hospital  Cases 

See  patient  as  soon  after  she  is  dismissed  as  possible,  to  make  sure 
she  understands  how  to  care  for  baby.  Urge  her  to  take  baby  to  nearest 
baby  health  station  (see  Blue  Card)  when  baby  is  three  weeks  old. 
Telephone  health  station  to  see  if  she  does  register.  Urge  her  to  bring 
baby  to  your  own  station  when  one  month  old.  At  that  time  arrange 
for  post-partum  examination :  if  it  is  the  practice  of  the  hospital,  at 
which  the  patient  was  delivered,  to  instruct  patient  to  return  for  post- 
partum examination,  urge  her  to  go  at  time  set  by  hospital;  if  not, 
urge  her  to  come  to  your  station  for  such  examination.  If  siie  fails 
to  come,  visit  her  to  learn  condition  of  baby,  and  to  urge  post-partum 


436  OBSTETRICAL  NURSING 

examination.  If  during  the  post-natal  follow-up  work,  any  abnormality 
is  discovered  in  baby  or  mother,  report  that  at  once  to  the  resident  of 
the  hospital,  where  patient  was  delivered,  and  carry  out  his  orders  as 
to  whether  patient  is  to  return  to  him  or  be  referred  to  gynecological 
or  baby  clinic. 
Patient  Delivered  at  Home 

Urge  all  pre-natal  cases  to  send  you  post  card  when  baby  is  born. 
When  postal  is  received,  visit  as  soon  as  possible  to  see  that  everything 
is  all  right;  arrangements  made  for  care  of  home  and  children  so  as 
to  keep  mother  in  bed  proper  time,  etc.  If  a  Henry  Street  nurse  is 
doing  post-partum  bedside  nursing,  make  no  other  visit  but  urge  mother 
to  bring  baby  to  see  you  at  station  when  the  baby  is  one  month  old. 
If  a  practical  nurse  or  a  midwife  case,  visit  every  day  or  so,  but  do 
not  interfere  with  her  conduct  of  the  case.  If  you  find  it  necessary 
to  report  any  irregularity  to  the  Department  of  Health  communicate 
with  the  midwife  before  doing  so.  After  she  has  dismissed  the  ease 
follow  the  routine  outlined  above.  Make  special  effort  to  get  all  mid- 
wives'  cases  to  come  for  post-partum  examination,  and  also  private 
physicians'  cases  if  they  dismiss  case  before  baby  is  six  weeks  old. 


CHAPTER  XX 

CARE  OF  THE  MOTHER  AND  BABY  BY  VISITING 

NURSES 

The  preventive  value  of  post-partum  care  is  now  so  gen- 
erally recognized  that  maternity  care  by  visiting  nurses  is  given 
not  only  in  the  larger  cities,  but  is  being  extended  even  to  rural 
communities.  The  routine  of  the  Visiting  Nurse  Society  of 
Philadelphia,  under  the  direction  of  Miss  Katharine  Tucker, 
may  be  taken  as  an  example  of  effective  post-partum  care,  in 
which  daily  visits  by  a  nurse  bring  to  large  numbers  of  patients 
the  minimum  of  necessary  attention.  As  the  same  kind  of  work 
is  effective  and  possible  in  smaller  communities,  the  routines 
and  instructions  used  by  the  Philadelphia  Society  are  repro- 
duced on  pp.  439  to  445.    These  include 

1.  The  equipment  of  the  niu-se's  bags. 

2.  Delivery  routine. 

3.  Routine  technique  in  caring-  for  mother  and  baby. 

In  normal  maternity  cases,  a  visit  is  made  once  a  day  for 
eight  days.  After  that  time,  if  the  mother  is  up  and  about  and 
the  baby  is  in  good  condition,  the  nurse  visits  at  least  once  a 
week  for  supervision  until  the  fifth  week,  when  the  case  is  trans- 
ferred automatically  to  the  Child  Welfare  Nurses  under  the 
City.  If,  however,  there  is  any  complication  with  either  the 
mother  or  baby,  the  nurse  continues  daily  visits  or  twice  daily 
as  indicated  by  the  condition,  until  both  mother  and  baby  are 
normal.  Instruction  to  the  mother  in  the  care  of  the  baby  is 
one  of  the  important  phases  of  the  maternity  nurse's  program. 

The  points  observed  and  recorded  on  the  bedside  cards  are : 
condition  of  breasts,  urination,  condition  of  bowels,  character 
of  lochia,  position  of  uterus,  T.P.R.  or  any  abnormality.  If 
there  is  any  rise  in  temperature  or  other  abnormality  noted,  the 
physician  is  called  by  telephone  and  the  situation  reported 

437 


438  OBSTETRICAL  NURSING 

Any  one  can  call  the  nurse — children,  husband,  neighbor, 
doctor,  social  worker, — and  a  nurse  is  sent  out  on  every  call.  A 
doctor  must  be  in  charge  of  every  case,  and  if  one  has  not  been 
engaged  when  the  nurse  gets  there,  she  sees  to  it  that  one  is  pro- 
cured. The  only  exception  is  in  cases  delivered  by  midwives,  in 
which  instances  the  nurse  gives  any  necessary  care  and  super- 
vision, having  it  clearly  understood  that  if  any  abnormality 
occurs,  she  will  first  notify  the  midwife  and  then  the  midwife  or 
the  nurse  will  immediately  call  a  doctor. 

The  doctor  ordinarily  brings  his  own  equipment  for  delivery. 
The  contents  of  the  nurse's  bag  is  the  same  for  delivery  as  for 
post-partum  care,  except  for  the  addition  of  the  nurse's  gown, 
extra  towels  and  silver  nitrate.  Perineal  pads,  cotton,  boric  solu- 
tion, etc.,  are  supplied  at  cost,  or  free  of  charge  if  the  patient  is 
unable  to  pay.  Bed  linen,  nightgowns,  layettes,  etc.,  are  pro- 
vided for  patients  who  cannot  procure  them. 

The  cost  per  visit  to  maternity  patients  averages  one  dollar 
and  the  cost  for  services  at  the  time  of  confinement  averages  five 
dollars.    Miss  Tucker  says  of  the  maternity  work: 

"A  eomplete  maternity  service  which  includes  prenatal  work,  service 
at  time  of  confinement,  post-partum  care  and  subsequent  supervision 
of  mother  and  baby  is  essential  if  adequate  results  are  to  be  accom- 
plished. Anything  less  than  this  complete  service  does  not  give  full 
protection  to  the  life  of  the  mother  and  the  baby.  The  Philadelphia 
Visiting  Nurse  Society  has  found  that  the  inclusion  of  service  at  time 
of  confinement  has  given  a  tremendous  stimulation  to  both  their  pre- 
natal and  postnatal  service.  In  the  branches  where  a  delivery  service 
has  been  added,  the  prenatal  service  has  increased  fourfold.  Both 
doctors  and  patients  are  enthusiastic  and  see  far  more  reason  for  in- 
struction and  supervision  from  a  nurse  who  is  going  to  see  the  case 
through  than  from  one  who  drops  out  at  the  crucial  moment.  It  cer- 
tainly has  strengthened  our  whole  maternity  service,  both  as  to  results 
accomplished  and  in  our  relationship  to  the  doctor  and  to  the  com- 
munity." 


CARE  OP  THE  MOTHER  AND  BABY  439 

FORMS  AND  ROUTINES  FOR  MATERNITY   WORK, 

VISITING  NURSE  SOCIETY 

PHILADELPHIA 

EQUIPMENT   FOB  BAGS 

Bottles  containing: 

1.  Alcohol. 

2.  Licreolisis. 

3.  Green  soap. 

4.  Mouth  wash. 

Jar  with  boric  acid  crystals. 
Jar  with  cord  powder. 
Jar  containing-  vaseline. 

1.  Hypodermic  syringe. 

2.  Tongue  depressors. 

3.  Two  thermometers :  rectal  and  mouth. 

4.  Toothpicks. 

5.  Adhesive  plaster. 

6.  Fountain  syringe  or  funnel  and  tube  in  linen  bag. 

7.  Gauze  and  bandages  in  linen  bag,  cord  dressing  and  cord  tape. 

8.  Cotton  and  p.p.  pads  in  linen  bag. 

9.  Paper  napkins  on  which  to  lay  articles. 

10.  Granite  pan. 

11.  Two  towels. 

12.  One  apron. 

13.  Handbrush. 
Instrument   case   containing : 

Scissors,  forceps,  2  artery  clamps,  glass  catheter,  rubber  catheter, 
colon  tube,  connecting  tube,  glass  nozzle,  medicine  dropper. 
Folder  containing: 
Records. 
Fee  slips. 
Literature. 

ROUTINE   TECHNIQUE 

1.  Uniforms. 

Except  in  the  case  of  substitutes  during  their  first  six  months  and 
staff  nurses  during  their  probation  period,  all  the  nurses  are  required 
to  wear  the  uniform  of  the  Society. 

Prescribed  hat  and  coat. 

Sensible  black  shoes. 

Plain  dress  of  prescribed  matei'ial. 

2.  Bags. 

Lining  to  be  changed  once  in  two  weeks. 
Bottles  to  be  kept  neatly  labelled. 


440  OBSTETRICAL  NURSING 

Lost  articles  to  be  replaced  at  *^lie  expense  of  the  nurse. 

New  equipment  may  be  obtained  only  in  exchange  for  the  worn- 
out  one. 

Notebooks,  charts,  other  papers,  and  pencils  to  be  kept  in  the  long 
pocket. 

Instruments  to  be  boiled  before  and  after  dressings. 

Brush  to  be  boiled  twice  a  week  and  after  all  infectious  cases. 

3.  Thermometer  Disinfection. 

To  be  washed  before  and  after  using-  in  running-  water  if  possible. 
After  using-  wrap  in  cotton  soaked  in  alcohol  and  leave  i;ntil  the 
work  is  finished.     Then  wash  with  green  soap  under  running  water. 

4.  Routine  in  the  Home. 

G-eneral  Care: 

A.  Remove  hat  and  coat,  folding  coat  right  side  out  and  placing 

on  chair  away  from  wall.  Place  bag  on  chair  or  on  table  with 
newspaper  underneath. 

B.  Ask  nature  of  illness,  doctor's  orders,  etc. 

Ask  family  for  a  kettle  of  boiling  water ;  pitcher  of  cold  water ; 
basin,  soap  and  soap  dish;  pail  for  the  waste;  tumbler;  towels 
and  wash  cloth;  bath  blanket  or  sheet;  clean  gown  and  neces- 
sary bed  linen ;  newspapers ;  comb  and  brush. 

C.  Open  the  bag;  put  on  apron;  roll  up  sleeves;  take  from  bag 
necessary  articles,  placing  on  clean  newspaper  or  napkin. 
Wash  hands  and  thermometer.  Take  everything  needed  from 
the  bag  at  once  to  prevent  unnecessary  handling.  Take  and 
record  T.P.R.  of  all  cases  except  chronics  of  long  standing. 

D.  Place  newspapers — one  on  chair,  one  under  edge  of  bed  for 
soiled  linen,  one  for  utensils   (kettle,  pitcher,  etc.) 

Make  cornucopia  of  newspaper  for  waste  and  pin  to  the  side 
of  bed. 

E.  Bath.     Cover  patient  with   blanket  or  sheet. 
Remove  upper  bed  clothes,  fold  and  place  on  chair. 

Soiled  linen  should  be  placed  on  paper  with  the  stains  turned 

in. 
Avoid  unnecessary  exposure  of  the  patient  at  all  times. 
Give  thorougli  bath,  nsing  plenty  of  soap  and  rinsing  carefully. 
Change  water  at  least  once. 
Bathe  upper  half  of  body,  give  local  bath,  change  water  and 

bathe  lower  half. 
Put  on  nightdress  before  completing  bath. 
Clean  teeth  and  nails. 
Comb  hair,  protecting  pillow  with  towel. 
In  making  the  bed  be  sure  that  there  are  no  wrinkles  under  the 

patient  and  that  the  bed  clothes  are  neatly  tucked  in. 


CARE  OF  THE  MOTHER  AND  BABY     441 

F.  Clear  room  of  articles  used.    Empty  basin.    Wrap  soiled  linen 
in  paper. 

Burn  cornucopia  before  leaving  the  house. 

Wash  hands. 

Complete  bedside  record,  si^n  receipt  for  fees,  and  place  in  an 

envelope. 
Instruct  the  family  to  give  it  to  the  doctor, 

G.  Instruct    the   Family 

1.  To  have  hot  water  and  necessaiy  articles  ready  for  the  next 

visit. 

2.  To  keep  rttnni  clcjin  and  well  ventilated  and  emphasize  the 

importance  of  damp  dusting  and  sweeping. 

3.  To  have  table  cleared  tor  patient's  u.se. 

4.  About  the  care  to  be  given  between  visits. 

Choose  most  suitable  member  of  the  faiuily  and  instruct  care- 
fully. 
H.     Observe  general   health   of  other  members  of  family  and  the 
hygienic  conditions  of  the  home. 

Partial  Care : 

Prepare  as  for  general  care. 

Bathe  the  patient's  hands,  face,  neck,  axilla,  and  breasts,  and 

give   local   bath.     With  maternity  cases   do  post-partum 

dressing. 
Cleanse  the  mouth. 
Make  bed  as  in  general  care. 

DELIVERY    ROUTINE 

Ektra  articles  to  be  carried  in  bags :  gown,  2  towels,  clamps,  2% 
silver  nitrate  solution. 

The  doctor  should  be  called  at  the  same  time  as  the  nurse.  This 
should  be  ascertained  when  call  is  taken  over  telephone. 

If  the  nurse  arrives  first,  she  should  judge  from  the  progress  of 
labor  whether  an  urgent  call  should  be  sent  for  the  doctor  and  how 
much  time  she  will  have  to  spend  in  preparation  for  the  deliveiy.  Un- 
less directed  otherwise  bj^  doctor,  the  nurse  should  proceed  as  follows : 

Have  a  supply  of  boiled  water  and  pour  some  in  covered  vessel 
to  cool. 

Take  necessary  articles  from  bag,  wash  hands,  put  on  gown. 

Prepare  patient  by  giving  enema,  sponge  bath,  braiding  the  hair, 
putting  on  clean  white  stockings  and  a  gown  which  can  be  rolled  up 
around   waist. 

Make  bed  with  tight  sheet,  oilcloth  and  draw  sheet,  f)rotect  with 
pads  made  of  many  thicknesses  of  newspajier,  covered  with  old  muslin. 

Protect  floor  with  newspapers,  and  place  basin  for  placenta.     On 


442  OBSTETRICAL  NURSING 

bedside  table,  place  alcohol,  sneen  soap,  glass  of  boric  acid  solution, 
silver  nitrate,  basin  containing  scissors,  clamps,  catheter,  medicine  drop- 
per, cotton  gauze,  cord  tape  and  dressing,  perineal  pads,  hyperdermic, 
thermometer.  Basin  of  h'sol  within  reach.  Prepare  a  place  for  baby 
by  covering  pillow  with  blanket  and  placing  hot  water  bottle.  Have 
olive  oil  (warmed).     Get  baby  clothes,  also  gown  and  binder  for  mother. 

Scrub  hands  and  cleanse  patient  locally  with  green  soap  and  water 
and  put  on  sterile  pad. 

Assist  doctor  in  any  way  possible  during  delivery. 

Ask  doctor  whether  he  wishes  to  instill  silver  nitrate  into  baby's 
eyes.     This  should  be  followed  by  normal  salt  solution  and  boric  acid. 

After  deliveiy,  cleanse  vulva  with  warm  lysol,  put  on  fresh  p,ad 
and  binder,  and  make  patient  as  comfortable  as  possible,  giving  her 
something  hot  to  drink. 

Weigh,  oil,  cleanse,  dress  baby.  Unless  doctor  orders  otherwise, 
instruct  mother  to  nurse  even'  three  hours  and  to  cleanse  nipples  with 
boric  acid  solution  before  and  after  nui-sing.  The  following  additional 
information  is  to  be  written  on  the  medical  history  card  of  patient 
attended  at  delivery- : 

1.  Time  nurse  arrived. 

2.  Time  baby  was  born  and  sex  and  weight. 

3.  Presentation. 

4.  Instrumental — high  or  low. 

5.  Laceration. 

6.  Repair,  kind  and  number  of  sutures. 

7.  HemoiThage. 

8.  Prophylactic  used  for  the  eyes. 

9.  Number  of  hours  in  labor. 

10.     Condition  on  discharge — fundus  and  lochia. 
This  technique  is  given  as  a  general  standard  but  the  nurse  is  ex- 
pected to  use  her  own  discretion  in  adapting  it  to  the  condition  of 
patient,  the  home  surroundings  and  the  wishes  of  the  doctor. 

ROUTINE   AFTER  DEX,rV'ERY 

Care  of  the  Baby: 

A.     Make  preparations  as  for  general  care. 

Have  everything  ready  before  the  baby's  bath. 

Have  separate  basin  for  the  baby  whenever  possible. 

Test  temperature  of  water  with  the  elbow. 

If  the  room  is  cold  bathe  in  the  kitchen. 

Use  table  whenever  possible  for  the  baby's  bath. 

If  not  possible  sponge  on  lap  beside  the  mother's  bed  so  that  she 
can  observe  technique. 

When   cord   is   off,   tub. 

Place  on  paper  napkin  on  third  chair,  table,  or  corner  of  dresser, 


CARE  OF  THE  MOTHER  AND  BABY     443 

glass  of  boracic  acid  sol.,  olive  oil,  warmed,  cord  powder,  and  dressings, 
safety  pins,  band,  absorbent  cotton,  rectal  thermometer,  vaseline  and 
alcohol.  Have  baby's  clothes  within  easy  reach.  Protect  lap  with 
blanket  or  bath  towel. 

Remove  clothing. 

To  protect  cord  dressing,  unpin  but  do  not  remove  band. 

Take  temperature  first  and  last  visit,  and  when  indicated. 

Weigh  baby  on  fii"st  and  last  visit. 

Examine  carefully  for  any  abnormalities  and  note  when  found. 

B.  Eyes. 

Unless  there  is  a  secretion,  let  the  eyes  alone. 

When  secretion  or  redness,  wash  eyes  gently  with  2%  Boric  acid  sol. 
using  separate  pledget  for  each  eye. 

C.  Mouth. 
Examine  mouth. 

No  treatment  unless  required. 

If  necessary  to  cleanse  use  cotton  wrapped  around  little  finger  and 
dipped  in  boracic  acid. 

D.  Nose. 

Xo  treatment  imless  required. 

If  necessary-  use  piece  of  twisted  cotton  and  boracic  acid  sol. 

Never  use  toothpicks. 

E.  Wash  face  "and  ears  gently  with  wash  cloth  or  absorbent  cotton 
and  drj-. 

Soap  head  with  hands,  rinse  with  cloth  and  dry  carefully.  Soap 
body  with  hands,  rinse  with  cloth  and  pat  diy  with  soft  towel.  Fold 
binder  across  abdomen,  protect  with  hand  and  turn  baby  on  stomach. 
Bathe  the  back.     Fold  diaper  and  place  under  buttocks. 

F.  Genitals  should  be  carefullj'  cleansed. 

In  the  ease  of  boys,  the  foreskin  should  be  gently  pushed  back  once 
in  every  two  or  three  days,  and  the  parts  underaeath  bathed  carefully 
with  absorbent  cotton  and  boracic  acid  sol.,  removing  the  white  pasty 
material  which  causes  irritation. 

In  the  case  of  girl  babies,  carefully  bathe  genitalia.  If  deposit  is 
difficult  to  remove,  soften  with  olive  oil. 

G.  On  first  visit  wash  umbilicus  with  70'~f  alcohol  and  apply  drj' 
sterile  dressing.  Do  not  remove  this  dressing  except  when  soiled.  After 
the  first  time  dress  with  cord  powder.  Put  on  clean  binder,  pinning 
on  side  with  safety  pins.     Oil  under  arms,  buttocks  and  all  creases. 

Put  on  shirt. 

Pin   diaper. 

Petticoat  and  dress  should  be  drawn  on  over  the  feet. 

Use  hot  water  bottle  filled  with  warm,  not  hot,  water. 

If  necessary  beer  bottle,  tightly  corked,  is  a  good  substitute. 


444  OBSTETRICAL  NURSING 

Clear  away  articles  used  for  the  baby. 
H.     Points  to  be  observed,  recorded  and  reported  to  the  physician  if 
urgent : 

1.  Condition  of  cord. 

2.  Eyes;  discharge,  swelling  or  redness, 

3.  Urination  and  stools. 

4.  When  foreskin  is  veiy  tight  and  in  every  case  when  it  cannot 
be  easily  pushed  back. 

I.     Instruct  the  Mother: 

1.  To  nurse  every  three  hours  unless  otherwise  ordered. 

2.  To  cleanse  nipples  with  boracic  acid  sol.  before  and  after  nurs- 
ing, and  to  keep  the  breasts  covered  with  clean  cloth. 

3.  To  give  cooled,  boiled  water  at  least  twice  a  day  between  feedings. 

4.  If  fluid  appears  in  the  baby's  breasts,  caution  the  family  not 
to  touch. 

J.  Do  not  discharge  the  baby  until  cord  is  off,  umbilicus  is  in  good 
condition  and  no  further  nursing  care  required.  Premature  babies 
should  be  oiled  and  wrapped  in  cotton.  Premature  jackets  can  be  se- 
cured from  the  V.N.S.  for  35  cents. 

Care  of  Mother: 

Make  preparations  as  for  general  care. 
Extra  articles  needed : 

1.  Pitcher  for  solution. 

2.  Glass  for  boracic  acid. 

3.  Absorbent    cotton. 

4.  Dressings, 

5.  Binder, 
Take  T.P.R. 

Give  complete  bath, 
Post-partum  dressing: 

1.  Make  sol.  of  lysol  in  pitcher   (or  glass  jar)   which  has  been 
washed  and  scalded. 

Directions   for  lysol    Sol. :    Use   V2   teaspoon   lysol    to   1   quart 
hot  Avater. 

2.  Place  paper  napkin  on  table  or  chair  at  side  of  bed  and  on  it 
pledgets  of  cotton,  and  clean  pads. 

3.  Arrange  sheet  or  bath  blanket  to  avoid  exposure. 

4.  Place  soiled  pad  in  cornucopia. 

5.  Place  clean  douche  pan  or  basin  under  patient, 

6.  Scrub  hands  with  green  soaf)  and  brush  under  running  water. 

7.  Pour  sol,  over  vulva.     Use  i>ledgets  for  cleaning  vulva,  wiping 
always  towards  rectum. 

Dxy    thoroughly    with    pledgets. 


CARE  OF  THE  MOTHER  AND  BABY     445 

8.  Remove  pan. 

Turn  patient  on  side  and  wipe  from  perineum  back  over  rectum 

■with  pledget.     Dry. 

Dry  back  and  put  on  pad. 

Wbile  in  this  position  place  binder  and  draw  sheet. 

9.  Wash  hands. 

10.  Binder. 
Locate  fundus. 

Draw  edges  of  binder  together  and  begin  pinning  from  fundus 

down. 

Then  pin  from  fundus  up,  taking  dart  in  either  side. 

Fasten  pad  to  binder,  front  and  back. 

Unless  especially  ordered  the  binder  may  usually  be  replaced 

by  a  T-binder  on  the  fourth  day. 

11.  Complete   as   in   general   care. 

Points  to  be  observed  and  recorded  on  bedside  notes  if  neces- 
sary: 

1.  Condition  of  the  breasts. 

2.  Urination. 

3.  Condition  of  bowels. 

4.  Lochia. 

5.  Position  of  uterus. 
Record  any  abnormal  conditions. 

Do  not  massage  breasts  unless  ordered. 

Full  post-partum  care  to  be  given  on  first  visit  if  possible. 

Give  general  care  every  other  day. 
Douche. 

When  douche  is  ordered  boil  nozzle  before  and  after  lusing. 

Boil  douche  bag  before  using  and  wash  aftem^ards — use  boiled  water. 

When  sutures,  instruct  the  family  how  to  irrigate  after  urination 
and  movement  of  the  bowels. 

Normal  maternity  cases  should  be  visited  daily  until  after  the  8th 
day  of  puerpeiium  and  at  least  once  a  week  for  supervision  until  the 
5th  week.    The  case  is  then  transferred  to  Child  Welfare  nurse. 

Additional  visits  should  be  made  if  the  patient  is  still  in  bed  and 
there  is  no  intelligent  adult  to  give  care,  or  if  the  baby's  condition  is 
not  satisfactory. 

A  SUGGESTION  FROM  MONTREAL 

Ingenuity,  resourcefulness,  and  ((iiick  wit  on  the  part  of  an 
intelligent  nurse  can  almost  always  apply  hosjiital  ideals  to 
circumstances  which  would  at  first  seem  hopeless.  It  is  the 
nurse's  knowledge  of  obstetrical  nursing  and  principles,  rather 
than  her  equipment,  that  counts  in  saving  lives.    The  following 


446  OBSTETRICAL  NURSING 

directions  given  to  visiting  nurses,  by  Cecil  A.  K.  Dawkins,  R.N., 
Supervisor  of  the  Outdoor  Department  of  the  Montreal  Ma- 
ternity Hospital,  indicate  the  possibility  of  clean,  efficient  care 
in  conditions  far  from  ideal : 

"maternity  case  conducted  in  a  house  where  there  is 

VERY   little  to  WORK   WITH 

"Appliances  You  Are  Likely  to  Find  in  Any  House: 

"Bed,  table,  cliaii',  twu  boxes,  basin,  i)ail^  kettle,  saucepan,  plate,  two 
cups,  spoon,  several  fair  sized  bottles,  sbeet,  two  towels,  pillow,  pillow 
case,  handkerchief,  newspapers,  old  clean  rags,  small  package  boracic 
powder,  small  bottle  vaseline,  soap,  baby  clothes. 

"Doctor's  bag-  will  nsually  contain  towel,  clamps,  scissors,  ergot, 
chloroform,  creolin,  rnbber  apron,  hypodermic  syringe,  nail  brush. 

"1.  I  would  take  a  look  at  the  fire.  Put  on  the  kettle  to  boil,  also 
saucepan  containing  scissors,  clamps,  hypo  (cord  ligatures), 
clean  rags  to  use  as  sponges,  if  absorbent  is  not  available.  I 
would  put  several  pieces  of  clean  rag-  (some  small  for  cord 
dressings,  others  large  for  vulva  pads)  on  a  plate  in  the  oven 
to  bake.  This  will  only  take  a  minute. 
"2.  Attack  the  bed.  Strip  it,  place  a  good  pad  of  newspapers 
where  the  patient  is  to  lie.  Then  the  sheet.  Cover  this  all  over 
with  newspapers,  jiarticularly  where  the  patient  lies.  Here  I 
would  form  a  Kelly  pad,  rolling:  the  jiaper  up  at  the  top  and 
bottom  and  left  side,  the  right  side  falling'  over  the  edge  of  the 
bed  into  the  pail.  Cover  with  clean  rag.  Paper  under  the  pail. 
"3.  Place  basin,  towel,  soap  and  nail  brush  on  table.  Wash  up  and 
prepare  patient.  Braid  her  hair.  Put  on  a  clean  nightdress. 
"4.  Clip  away  the  pubic  hair  with  scissors,  if  razor  not  available 
to  shave.  Give  S.S.  enema,  provided  you  have  the  time  to  do 
it  in,  and  the  syringe  to  do  it  with.  Wash  the  vulva  well  with 
soap  and  water.  Put  on  pad,  rag  wet  with  disinfectant. 
"5.  The  instruments,  swabs,  etc.,  should  be  boiled  by  this  time. 
Place  scissors  and  clamps  on  jjlate,  and  swabs  in  basin.  Get 
hypo  ready.  Water  for  ergot.  Boracic  for  baby's  eyes.  Baby's 
clothes  together, — also  warm  cloth  to  wrap  baby  in.  Fold 
handkerchief  crosswise,  and  make  funnel  for  chloroform  mask. 
"6.  When  baby  comes,  wrap  him  up  warmly,  and  place  on  the  right 
side  in  a  safe  place.  If  no  other  place  available,  pull  bureau 
drawer  half  open  and  put  him  in,  but  be  careful  not  to  close 
it  again. 

The  plate  that  has  held  the  scissors  and  clamps  may  be  used 
for  the  placenta. 


CARE  OF  THE  MOTHER  AND  BABY      447 

"7.  To  clean  up  the  bed  and  make  the  patient  comfortable,  roll  her 
on  her  right  side,  rolling  the  paper  up  to  her  back.  Wash  her 
and  turn  her  on  her  left  side,  removing  paper.  Put  on  a  clean 
pad  and  "T"  binder. 

''8.  A  jug-  of  boiled  water  left  to  C(jol  would  be  useful  in  emergency, 
— as  also  several  glass  bottles  filled  with  hot  water  for  ease  of 
shock.    The  boxes  may  be  used  for  raising  the  foot  of  the  bed." 


Yet  it  is  but  a  little  human  babe, 
Given  at  last  into  his  reaching  arras 
And  carried  to  the  hollow  of  her  breast! 

Marguerite  Wilkinson. 


PART  VII 
THE  CARE  OF  THE  BABY 

CHAPTER  XXI.  CHARACTERISTICS  AND  DEVELOPMENT  OF  THE 
AVERAGE  NEW-BORN  BABY.  New  Functions.  Description. 
Growth  and  Development.  Weight.  Height.  Head  and  Chest. 
Fontanelles.  Teeth.  Stools  and  Urine.  Skin.  Tears.  General 
Behavior. 

CHAPTER  XXII.  NURSING  CARE  OF  THE  NEW-BORN  BABY. 
Mortality  of  First  Months  and  Year  of  Life.  Preventable  Causes. 
Dangers  of  Babyhood.  Essential  Features  of  Early  Care.  Daily 
Schedule.  Bath.  Clothes.  Fresh  Air.  Exercise.  Training  the  Baby. 
Bowels.  Thumb-sucking.  Ear-pulling.  Crying.  Ruminating.  Feed- 
ing: Breast  Feeding.  Artificial  Feeding.  Necessary  Characteristics 
of  Artificial  Food.  Requirements  for  Milk  Used.  Articles  Needed 
in  Preparing  Food.  Preparation  of  Milk.  Pasteurization.  Boiling. 
Giving  the  Bottle.  Ingredients  of  Food.  Percentage  Feeding. 
Average  Formulae.  Mixed  Feeding.  Commercial  Baby  Foods.  Pro- 
prietary Foods,  Canned  Milks,  Milk  Powders.  Other  Articles  of 
Food  Sometimes  Included  in  Baby  Diet.  Travelling.  The  Prema- 
ture Baby.     Summer  Care  of  the  Baby. 

CHAPTER  XXIII.  COMMON  DISORDERS  AND  ABNORMALITIES 
OF  EARLY  INFANCY.  Malnutrition,  Marasmus  and  Inanition. 
Diarrheal  Diseases:  Acute  Gastro-enteritis.  Symptoms.  Treatment 
and  Nursing  Care.  Acidosis.  Colic,  Constipation,  Convulsions,  and 
Vomiting.  Infections:  Ophthalmia  Neonatorum.  Symptoms,  Treat- 
ment, and  Nursing  Care.  Syphilis.  Thrush,  or  Sprue.  Impetigo. 
Pemphigus.  Vaginitis.  Abnormalities:  Icterus  or  Jaundice.  Cephal- 
ematoma.  Club  Foot.  Engorgement  of  Breasts.  Hare  Lip.  Cleft 
Palate.     Hernia. 


CHAPTER  XXI 

CHARACTERISTICS  AND  DEVELOPMENT  OF  THE 
AVERAGE  NEW-BORN  BABY 

Before  undertaking  the  care  of  the  new-born  baby  the  nurse 
should  stop  and  consider  him  for  a  moment  and  review  in  her 
mind  just  what  he  represents;  what  he  has  been  through;  what 
struggles  and  dangers  are  ahead  of  him ;  what  are  the  weaknesses 
of  his  equipment  to  meet  these  perils  and  what  must  be  the 
the  character  of  her  service  to  him  if  she  is  to  do  all  in  her  power 
to  help  him  safely  over  that  most  hazardous  period  in  the  entire 
span  of  his  existence :  the  first  month  of  his  life. 

That  little  new-born  baby  is  quite  as  helpless  and  appealing 
as  he  looks,  for  his  chances  for  present  and  future  health  lie  very 
largely  in  the  hands  of  those  who  care  for  him  during  these 
early  weeks,  and  any  injury  which  is  done  at  this  time,  either 
through  acts  of  omission  or  commission,  can  never  be  entirely 
repaired. 

At  the  time  of  birth,  the  baby  makes  the  most  complete  and 
abrupt  change  in  his  surroundings  and  condition  that  he  will 
make  during  his  entire  lifetime. 

He  has  existed  and  evolved  as  a  parasite  for  nine  months, 
during  which  time  he  has  been  protected  from  injury ;  kept 
at  the  temperature  which  was  best  for  him,  and  above  all  has 
been  furnished  with  exactly  the  proper  aijiount  and  character  of 
nourishment  necessary  for  his  growth  and  development. 

Suddenly  he  emerges  from  this  completely  protecting  envi- 
ronment into  a  more  or  less  hostile  world,  where  he  must  begin 
life  as  a  separate  entity  with  a  frail  little  body  that  in  many 
respects  is  only  imperfectly  developed.  And  yet  the  baby  must 
not  only  continue  the  bodily  functions  and  activities  that  were 
begun  during  his  uterine  life,  but  must  also  elaborate  and  es- 
tablish others  which  were  imperfect  or  were  performed  for  him. 
Otherwise  he  will  not  live. 

451 


452  OBSTETRICAL  NURSING 

The  nurse  will  recall  that  the  fetus  received  its  nourishment 
and  oxygen,  and  gave  up  waste  material,  through  the  placental 
circulation ;  that  the  lungs  were  not  inflated  and  that  most  of  the 
blood  flowed  through  the  foramen  ovale  instead  of  through  the 
pulmonary  vessels,  as  it  does  after  birth.  The  digestive  tract, 
excretory  organs  and  nervous  system  were  not  needed  during 
fetal  life  and  therefore  are  imperfectly  developed  at  birth  and 
are  capable  of  functioning  only  Avithin  very  narrow  limits. 

The  pulmonary  circulation  usually  is  established  immediately 
after  birth,  and  when  the  baby  cries  vigorously  the  lungs  are 
expanded  and  filled  with  air  and  the  respiratory  function  is 
inaugurated.  The  ductus  arteriosus,  ductus  venosus  and  two 
hypogastric  arteries  are  gradually  obliterated,  as  the  normal 
circulation  of  the  blood  becomes  established  and  the  foramen 
ovale  is  closed.    See  Figs.  28  and  29. 

The  other  functions  are  established  more  slowly  and  the  care 
of  the  baby  must  be  such  that  the  immature,  unused  organs  will 
not  be  overtaxed,  and  yet  that  their  development  will  be  pro- 
moted through  activity. 

The  new-born  baby  weighs  3250  grams,  or  7^/4  pounds,  and 
is  about  50  centimetres,  or  20  inches  long.  The  body  is  well 
rounded  and  the  flesh  firm.  The  skin  is  a  deep  pink,  or  even  red, 
and  is  covered  with  a  white,  cheesy  substance,  the  vernix  caseosa, 
which  is  likely  to  be  thickly  deposited  in  the  folds  of  the  skin, 
in  the  creases  of  the  thighs  and  axilla  and  over  the  back.  Some 
babies  still  have  the  fine,  downy  lanugo  hair  over  parts  or  all 
of  the  body. 

The  head  and  abdomen  are  relatively  large,  the  chest  narrow 
and  the  limbs  short.  The  legs  are  so  markedly  bowed  that  the 
soles  of  the  feet  may  nearly  or  quite  face  each  other,  but  they 
finally  assume  a  normal  position.  The  bones  are  largely  cartilage 
and  the  entire  body  is  therefore  very  flexible.  Some  of  the  bones, 
which  are  separate  at  birth  unite  later  in  life  and  the  adult 
skeleton  finally  becomes  firm  and  rigid. 

Most  babies  have  faded  blue  eyes  at  birth,  the  permanent 
color  appearing  gradually,  while  the  amount  and  color  of  the 
hair  varies  greatly,  some  babies  being  bald  and  others  having 
abundant  hair  from  the  beginning. 


DEVELOPMENT  OP  AVERAGE  NEW-BORN  BABY   453 

The  shape  of  the  baby's  head  is  sometimes  distorted  at  birth, 
being  so  elongated  from  chin  to  occiput  as  to  give  tlie  parents 
deep  concern.  But  they  may  be  confidently  assured  that  in  the 
course  of  a  few  days  the  head  will  assume  the  lovely  rounded  con- 
tour, so  characteristic  of  babyhood.  The  temporary  deformity 
is  caused  by  a  moulding  and  overlapping  of  the  bones  of  the 
skull  as  it  is  forced  through  the  birth  canal,  and  sometimes  also 
to  a  collection  of  fluid  under  the  scalp,  called  the  caput  succe- 
daneum,  and  which,  too,  is  due  to  pressure  during  birth.  Both 
the  anterior  and  posterior  fontanelles  may  be  felt  at  birth. 

Growth  and  Development.  The  progress  during  the  first 
year,  of  average,  normal  babies  who  are  satisfactorily  nourished 
and  cared  for,  is  fairly  uniform  and  the  accepted  average  is  sug- 
gested by  the  following  schedules  which  are  based  upon  observa- 
tions made  upon  a  large  number  of  normal,  healthy  infants. 

Weight.  The  average  baby  boy  weighs  at  birth,  7I/4  to  ly^ 
pounds  and  girls  a  little  less,  as  a  rule.  There  is  an  initial  loss 
of  from  six  to  ten  ounces  during  the  first  week,  through  body 
waste  and  the  passage  o£  meconium  and  urine,  before  the  full 
amount  of  nourishment  is  taken  and  assimilated,  large  babies 
losing  more  than  small  ones..  (Chart  5.)  From  this  time  the 
gain  is  usually  from  four  to  eight  ounces,  each  week,  during  the 
first  five  months,  after  which  it  is  only  about  half  as  rapid,  or  at 
the  rate  of  from  two  to  four  ounces  weekly.  At  six  months, 
therefore,  the  average  baby  weighs  from  fifteen  to  sixteen 
pounds,  or  double  the  normal  birth  weight  of  7^/2  pounds,  and  at 
twelve  months,  from  twenty  to  twenty-two  pounds,  or  three 
times  the  average  birth  weight.  The  weight  is  perhaps  the  most 
valuable  single  index  to  the  baby's  condition,  that  w'e  have,  but 
at  the  same  time,  it  must  be  remembered  that  a  baby  whose  food 
is  rich  in  carbohydrates  may  be  of  normal  weight,  or  over,  but 
be  incompletely  nourished  and  very  susceptible  to  infection. 
Other  babies  who  are  small  and  seem  to  gain  unsatisfactorily  are 
sometimes  very  well  and  vigorous.  And  very  commonly  there 
are  periods  in  the  lives  of  entirely  normal  babies  when  there  is 
little  or  no  gain  in  weight.  This  may  occur  during  the  period 
from  the  seventh  to  the  tenth  month,  for  example,  or  during  very 
warm  weather.    But  the  baby's  weight  should  be  watched  care- 


454 


OBSTETRICAL  NURSING 


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DEVELOPMENT  OF  AVERAGE  NEW-BORN  BABY   455 

fully,  for  a  loss  or  prolonged  failure  to  gain  may  be  an  evidence 
of  faulty  nuti'ition  or  disease. 

Height.  The  average  height  at  birth  is  20  iiK-Iies,  though 
boys  may  measure  a  little  more  and  girls  a  little  less;  at  six 
months,  25  to  25yo  inches  and  at  one  year,  28  to  29  inches. 

Head  and  Chest.  The  circumference  of  the  head  and  chest 
are  about  the  same  at  birth,  the  chest  being  possibly  a  little 
smaller.  Both  measure  about  131/^  inches,  increasing  gradually 
to  about  161/2  inches  at  six  montlis  and  18  inches  at  the  end  of 
the  first  year. 

Fontanelles.  The  posterior  fontanelle  usually  closes  in  six 
or  eight  weeks  but  the  larger,  anterior  fontanelle  is  not  entirely 
obliterated  until  the  baby  is  eighteen  or  twenty  months  old. 
Closure  of  the  fontanelles  is  usually  late  in  rickets,  cretinism 
and  hydrocephalus  and  early  in  cases  of  malnutrition  and  micro- 
cephalus. 

Teeth.  Although  it  occasionally  happens  that  a  baby  has 
one  or  two  teeth  at  birth,  the  average  infant  has  none  until  the 
sixth  or  seventh  month,  Avhen  the  two  lower,  central  incisors 
appear.  After  a  pause  of  a  few  weeks  the  two,  upper,  central  in- 
cisors appear,  followed  by  the  two  lateral  incisors  in  the  upper 
jaw.  At  the  end  of  the  first  year,  therefore,  the  average  baby 
has  six  teeth,  or  eight,  if  the  lower,  lateral  incisors  have  come 
through  by  the  first  birthday,  as  they  sometimes  do.  (Fig.  148.) 
This  is  the  usual  course  of  dentition  during  the  first  year,  but 
there  are  wide  variations  among  entirely  well  and  normal  babies, 
the  first  tooth  sometimes  not  appearing  before  the  tenth,  eleventh 
or  even  twelfth  month.  But  as  a  rule  if  no  teeth  are  cut  by  the 
time  the  baby  is  a  year  old,  it  is  regarded  as  an  evidence  of 
faulty  nutrition,  perhaps  bordering  on  rickets. 

The  baby  who  is  properly  fed  and  cared  for  cuts  his  teeth 
with  little  or  no  trouble,  in  spite  of  the  widely  current  belief 
that  a  teething  baby  is  a  sick  baby.  We  have  no  way  of  estimat- 
ing the  numl)er  of  babies  who  die  needlessly  from  infections  and 
digestive  disturbances  because  of  this  fallacious  conviction.  For 
if  the  baby  is  sick  while  teething,  the  disturbance  is  all  too  fre- 
quently accepted  as  a  normal  occurrence  and  nothing  is  done 
until  too  late. 


456 


OBSTETRICAL  NURSING 


Frail,  delicate  babies  may  have  convulsions  each  time  that 
a  tooth  is  cut  and  if  a  baby  is  having  digestive  trouble  it  is  likely 
to  grow  worse  while  he  is  teething.  But  dentition  is  a  normal 
physiological  process  and  the  healthy,  properly  fed  baby  suffers 
little  or  no  inconvenience  at  this  time. 

The  care  of  the  baby 's  teeth  should  begin  when  the  first  tooth 
appears.     It  should  be  wiped,  front  and  back,  with  a  piece  of 

gauze  or  cotton  dipped  in  a  solu- 
tion of  boraeie  acid,  or  sodium 
bicarbonate  or  some  other  weak 
alkaline  wash,  to  neutralize  the 
acid  secretions  of  the  mouth 
which  start  decay.  After  the 
baby  has  five  or  six  teeth,  the  use 
of  a  very  soft  brush,  with  tooth 
paste,  is  often  advised,  the  teeth 
being  brushed  with  a  circular 
motion  or  from  the  gums  toward 
their  edges.  The  teeth  should  be 
wiped,  or  brushed,  morning  and 
evening  and  after  feedings.  The 
reason  for  such  close  care  of  the 
temporary  teeth  is  that  they 
serve  as  a  mould  or  brace  to 
hold  the  jaws  in  proper  shape 
for  the  permanent  teeth  which  appear  later.  If  the  **milk"  or 
deciduous  teeth  decay  or  crumble  away  before  the  jaws  are 
developed  to  the  point  when  the  permanent  teeth  appear,  these 
second  teeth  are  likely  to  be  crooked  and  uneven. 

Stools  and  Urine.  During  the  first  two  or  three  days,  the 
stools  are  of  dark  green,  tarry  material  called  meconium.  Me- 
conium consists  of  cast-off  cells  from  the  skin  and  intestines,  fat, 
mucus,  hairs  and  bile  pigment.  In  the  course  of  two  or  three 
days,  the  stools  begin  to  grow  lighter  and  shortly  the  normal, 
milk-feces  appear,  being  bright  yellow,  of  a  smooth  pasty  con- 
sistency and  having  a  characteristic  odor.  During  the  first 
month  or  six  weeks  the  baby's  bowels  may  move  three  or  four 
times  daily,  but  after  this  they  usually  mo\e  but  once  or  twice  in 


^    § 


r^  a  i  i 

CO  ^«    cvj    ii!    "^ 


o 


Fig.  148. — Diagram  of  first  or 
deciduous  teeth  and  ages  at  which 
they  usually  appear. 


DEVELOPMENT  OF  AVERAGE  NEW-BORN  BABY   457 

the  course  of  twenty-four  hours.  As  the  diet  is  increased,  the 
stools  grow  somewhat  darker  and  firmer  and  finally  become 
formed. 


Fig.  149. — Appearance  of  umbilical  cord  immediately  after  birth. 

The  new-born  baby's  bladder  usually  contains  urine  which 
may  be  voided  immediately  after  birth  or  not  until  several  hours 
later.     After  the  first  voiding  the  bladder  may  be  emptied  five 


Fig.   150.— Appearance  of  umbilical  cord,  four  days  after  birth. 

or  six  times  a  day,  or  oftener.  The  nurse  should  watch  for  the 
first  evacuation  of  the  bowels  and  bladder,  and  if  they  do  not 
occur  during  the  first  few  hours,  the  fact  should  be  reported  to 


458 


OBSTETRICAL  NURSING 


the  doctor,  as  the  omission  may  be  due  to  an  imperforate  anus 
or  meatus. 

Cord.     Within  a  few  days  after  birth  the  stump  of  the  um- 


FiG.  151. — Appearance  of  umbilicus  immediately  after  separation  of  cord. 

bilical  cord  begins  to  shrivel  and  turn  black,  and  a  red  line  of 
demarcation  appears  at  the  junction  of  the  cord  Avith  the  abdo- 
men. By  the  eighth  or  tenth  day,  as  a  rule,  the  cord  has  atro- 
phied to  a  dry  black  string,  when  it  drops  off  and  leaves  an  ul- 


FiG.  152. — Appearance  of  a  well  healed  umbilicus. 

cer,  or  small  granulating  area  which  heals  entirely  in  a  few  days. 
(Figs.  149,  150,  151,  152.)  Before  the  days  of  sepsis,  infections 
of  the  cord  were  not  uncommon  and  babies  frequently  died  of 
t;etanus,  streptococcus  and  other  infections.    But  at  the  present 


DEVELOPMENT  OP  AVERAGE  NEW-BORN  BABY  459 

time  an  infected  cord  is  a  rare,  and,  it  may  be  added,  an  almost 
inexcusable  occurrence. 

Skin.  By  the  end  of  the  tirst  week  any  lanugo  remaining 
usually  disappears  and  there  is  frequently  a  scaling  of  the  super- 
ficial layers  of  the  skin  which  lasts  for  two  or  three  weeks,  while 
a  delicate  pink  tint  replaces  the  deeper  color  of  the  skin  in  the 
course  of  ten  days  or  two  weeks.  The  baby  does  not  perspire  until 
after  the  first  month,  as  a  rule,  when  insensible  perspiration 
begins,  gradually  increasing  until  perspiration  is  free  by  the 
time  the  baby  is  a  few  months  old. 

Tears.  There  are  no  tears  at  birth  and  opinions  differ  as  to 
whether  they  appear  in  the  course  of  two  or  three  weeks,  or  three 
or  four  months.  The  absence  of  the  lachrymal  secretion  is  one 
explanation  for  the  necessity  of  bathing  the  baby's  eyes  during 
the  early  days  and  weeks,  for  if  dust  or  other  foreign  material 
gains  entrance  it  is  not  washed  out  by  the  tears  as  it  is  later. 

General  Behavior.  During  the  first  few  weeks  the  average 
baby  sleeps  most  of  the  time  :  that  is  from  nineteen  to  twenty-one 
hours  daily.  He  gradually  sleeps  less,  as  the  special  senses  de- 
velop and  will  sometimes  lie  quietly  for  an  hour  or  more  with  his 
eyes  open,  sleeping  only  sixteen  or  eighteen  hours  daily  at  six 
months  and  fourteen  to  sixteen  hours  at  the  end  of  a  year. 

The  baby  begins  to  make  noises  and  "coo"  at  about  two 
months  and  to  utter  various  vowel  sounds  when  about  six  months 
old.  By  the  end  of  a  year  these  indefinite  noises  and  sounds  be- 
come distinct  words.  At  about  the  fourth  month,  he  grasps  at 
objects  and  smiles  and  very  soon  even  laughs.  He  holds  up  his 
head  at  about  the  third  or  fourth  month ;  sits  up  and  also  begins 
to  creep  at  six  or  seven  months;  while  sometime  between  the 
ninth  and  twelfth  months  he  will  stand  by  holding  to  some  one 's 
hand  or  the  furniture,  and  will  begin  to  walk  with  assistance. 

These  degrees  of  development  at  different  ages  are  not  to  be 
taken  as  the  only  measure  of  normal  progress,  for  many  well 
babies  mature  more  rapidly  and  others  more  slowly  than  at  the 
rate  which  is  found  to  be  the  average. 

In  addition  to  these  fairly  specific  evidences  of  the  baby's 
condition  and  progress,  such  as  weight,  height  and  muscular  de- 
velopment, there  are  other  and  less  definite  indications  of  his 


460  OBSTETRICAL  NURSING 

well-being  which  the  nurse  must  watch  for  and  accord  a  very 
high  value. 

The  baby  who  is  well  and  is  being  properly  fed  in  all  re- 
spects, will  have  good  color ;  his  flesh  will  be  firm ;  he  will  take 
his  nourishment  with  a  certain  amount  of  eagerness  and  seem 
satisfied  afterward.  He  will  sleep  for  two  or  three  hours  after 
each  feeding;  will  sleep  quietly  at  night,  and  while  awake,  un- 
less he  is  wet  or  uncomfortable  for  some  other  good  reason,  he 
will  seem  contented,  good-natured  and  happy. 


CHAPTER  XXII 
NURSING  CARE  OF  THE  AVERAGE  NEW-BORN  BABY 

It  is  estimated  that  out  of  every  thousand  babies  born  alive, 
in  this  country,  forty  die  during  the  first  month  of  life,  and  that 
more  than  as  many  again,  or  about  eighty-five  all  told,  perish 
before  reaching  the  first  birthday. 

So  hazardous  is  this  period  of  early  infancy,  in  the  United 
States,  that  our  annual  loss  of  baby  life  is  between  seven  and 
eight  times  as  great  as  was  the  yearly  toll  of  our  young  men  dur- 
ing the  war,  for  upwards  of  200,000  babies  less  than  a  year  old 
die  each  year.  That  the  first  month  of  life  is  fraught  with 
greater  danger  than  any  which  follow  is  shown  by  the  fact  that 
about  100,000  of  these  deaths  occur  during  the  first  four  weeks. 

The  tragedy  of  these  figures  is  made  darker  by  the  knowledge 
that  at  least  half  of  the  l)al)ies  who  are  lost  die  from  preventable 
causes.    In  other  words,  they  die  from  lack  of  proper  care. 

That  is  the  significant  fact  for  the  obstetrical  nurse,  since 
more  and  more  frequently  she  has  the  young  baby  in  her  care 
during  the  crucial  first  month  and  inevitably  plays  an  important 
part  in  increasing  his  chances  to  live.  She  does  this  by  helping 
to  keep  the  w^ell  baby  well,  rather  than  by  nursing  a  sick  baby. 

The  dangers  which  make  babyhood  such  a  precarious  period 
may  be  grouped  very  largely  under  the  general  headings  of 
unfavorable  ante-natal  conditions,  nutritional  disturbances  and 
infections.  The  care  and  supervision  of  the  expectant  mother 
will  remove  many  of  the  unfavorable  ante-natal  causes.  Nutri- 
tional disturbances  and  infections  must  be  dealt  with  after  birth. 

Faulty  nutrition  may  result  in  rickets,  scurvy,  malnutrition, 
marasmus,  acute  inanition  or  the  less  serious  colic,  constipation 
or  diarrhea.  The  most  frequent  results  of  infection  among 
young  babies  are  the  respiratory  diseases  in  winter,  such  as 
bronchitis  and  pneumonia,  and  the  intestinal  disorders  in  sum- 
mer, commonly   referred  to   as  "summer   complaint."     Since 

461 


462  OBSTETRICAL  NURSING 

undernourished  babies  are  very  susceptible  to  infection,  the  two 
conditions  are  frequently  coincident. 

"With  the  baby's  frailty  and  imperfect  development  in  mind, 
as  well  as  the  needs  of  his  growing  body  and  the  evils  that  beset 
his  way,  we  can  understand  the  reasons  for  the  painstaking,  pro- 
tecting care  which  he  is  given  during  the  early  weeks  of  his  life. 

The  essential  features  of  this  care  are  as  follows : 

1.  Proper  feeding. 

2.  Fresh  air. 

3.  Regularity  in  his  daily  routine. 

4.  Cleanliness  of  food,  clothing  and  surroundings. 

5.  Maintenance  of  an  equable  body  temperature. 

6.  Conservation  of  his  forces. 

These  requirements  seem  so  rational  that  one  might  expect 
them  to  be  met  as  a  matter  of  course;  but  the  annual  sickness 
and  death  rate  among  babies  are  a  constant  reminder  that  they 
are  not. 

The  nurse  should  begin  by  arranging  a  daily  schedule  for 
the  baby's  feedings,  fresh  air,  bath,  sleep  and  exercise,  and  follow 
it  with  unfailing  regularity.  The  hours  for  the  nursings,  which 
vary  with  different  doctors,  will  constitute  the  greater  part  of  the 
daily  schedule,  and  for  a  baby  on  four  hour  feedings,  for  ex- 
ample, some  such  program  as  the  following  may  be  arranged : 

Feeding. 

Orange  juice  (when  ordered). 

Bath. 

Feeding. 

Out  of  doors. 

Feeding, 

Out  of  doors. 

Orange  juice  (when  ordered). 

In-door  airing  and  exercise   (when  ordered). 

Preparation  for  the  night. 

Feeding. 

Feeding. 

Feeding  (when  ordered). 

The  importance  of  punctuality  in  the  daily  routine  cannot  be 
stressed  too  often  and  it  is  one  aspect  of  the  baby 's  care  for  which 
the  nurse  is  absolutely  responsible.    No  matter  how  well  the  baby 


6 

a.m. 

8 

a.m. 

9 

a.m. 

10 

a.m. 

10.30  to 

2 

p.m. 

2 

p.m. 

2.30  to 

4 

p.m. 

4 

p.m. 

4  to 

5.3C 

)  p.m. 

5.30 

1  p.m. 

6 

p.m. 

10 

p.m. 

2 

a.m. 

NURSING  CARE  OP  AVERAGE  NEW-BORN  BABY      463 

is  nursed,  in  other  respects,  nor  how  skillfully  the  doctor  directs 
his  care,  the  baby  cannot  be  expected  to  progress  satisfactorily 
if  his  life  is  irregular. 

The  Bath.  The  first  office  which  the  nurse  usually  per- 
forms for  the  new-born  baby,  and  which  she  repeats  daily,  is  to 
bathe  and  dress  him.  The  bath  may  be  given  in  a  tub,  under  a 
spray  or  in  the  nurse's  lap,  according  to  the  wishes  of  different 
doctors,  while  sponge  baths  are  sometimes  given  with  soap  and 
water  and  sometimes  with  oil. 

The  first  bath,  particularly,  is  likely  to  be  an  olive  oil  sponge, 
given  immediately  after  birth,  before  the  baby  is  taken  from  the 
mother's  bedside,  and  many  doctors  have  the  sterile  cord  dress- 
ing and  abdominal  binder  applied  at  this  time.  This  oil  bath  is 
given,  not  alone  for  the  purpose  of  removing  the  vernix  caseosa, 
but  also,  to  lessen  the  radiation  of  body  heat,  which  the  baby  can 
ill  afford  to  lose.  When  such  a  practice  is  followed  it  only  re- 
mains for  the  nurse  to  dress  the  baby  and  place  him  in  his  crib 
to  sleep  undisturbed  for  several  hours. 

Some  doctors  have  the  baby  sponged  every  morning  with 
albolene  or  olive  oil,  instead  of  with  soap  and  water,  until  the 
cord  separates,  when  tub  bathing  is  adopted.  AVhen  the  daily 
bath  is  given  with  oil,  the  baby 's  thighs  and  buttocks  are  wiped 
clean  with  an  oil  sponge  each  time  that  the  diaper  is  changed. 
Other  doctors  have  the  babj^  's  first  bath  given  in  a  tub,  with  soap 
and  water,  while  still  others  who  fear  that  the  cord  may  be  in- 
fected by  immersing  the  baby,  have  him  sponged  with  soap  and 
water,  after  the  vernix  caseosa  has  been  softened  with  oil. 

Sponge  bathing  is  commonly  employed  for  all  babies  until 
the  cord  separates  and  for  frail  delicate  babies  or  those  suffering 
from  skin  trouble.  The  sponge  bath  may  be  given  in  the  nurse's 
lap  or  on  a  table  covered  with  a  pad,  either  method  being  satis- 
factory if  the  baby  is  kept  warm  and  comfortable.  But  one  in- 
clines to  the  idea  of  having  the  baby  bathed  in  the  nurse's  lap 
for  he  seems  happier  there ;  more  comfortable  and  less  frightened 
and  we  cannot  be  sure  that  these  factors  are  unimportant. 

The  best  time  for  the  dailj'  bath,  during  the  first  three  or 
four  months,  is  about  an  hour  before  the  second  feeding  in  the 
morning.    After  this  age  the  full  bath  is  sometimes  given  before 


464  OBSTETRICAL  NURSING 

the  six  o'clock  feeding,  in  the  evening,  for  a  bath  at  this  hour  is 
soothing  and  restful  and  often  helps  toward  giving  the  baby  a 
good  night. 

Preparation  for  the  bath  should  made  with  its  possible  effects, 
both  good  and  bad,  in  mind,  for  the  baby  may  be  helped  or 
harmed  according  to  the  skill  with  which  he  is  bathed.  He  must 
not  be  chilled  during  his  bath,  and  fatigue  and  irritation  must 
be  avoided  by  giving  it  quickly  and  Math  the  least  possible  han- 
dling and  turning.  These  ends  may  be  served  by  conveniently 
arranging  all  of  the  articles  which  will  be  needed,  on  a  low  table 
at  the  right  hand  side  of  the  nurse's  chair,  before  the  baby  is 
undressed. 

There  should  be  a  pitcher  of  hot  and  one  of  cold  water;  a 
bath  thermometer ;  two  soft  wash-cloths ;  soft  towels ;  bath 
blankets ;  Castile,  or  some  other  mild  soap ;  boracic  acid  solution ; 
sterile  cotton  pledgets;  large  and  small  safety  pins,  or  large 
ones  and  a  needle  and  thread  if  the  band  is  to  be  sewed  on ;  un- 
scented  talcum  powder;  sterile  albolene  or  olive  oil;  soft  hair 
brush  and  a  complete  outfit  of  clothing.  The  little  garments 
should  be  arranged  in  the  order  in  which  they  will  be  put  on,  the 
petticoat  slipped  inside  the  dress,  and  all  hung  before  the  fire 
or  heater,  to  warm. 

The  temperature  of  the  room  should  be  about  72°  F.  and  if 
it  is  possible  to  bathe  the  baby  before  an  open  fire  or  a  heater, 
so  much  the  better.  In  any  case  he  must  be  protected  from 
drafts.  A  sheet  hung  over  the  backs  of  two  straight  chairs  will 
serve  very  well  as  a  screen  if  no  other  is  available. 

The  tub  or  basin  should  be  about  three-quarters  full  of  water 
at  100°  F.  for  the  new  baby;  about  95°  after  the  third  month 
and  gradually  lowered  to  85°  F.  or  90°  F.  for  the  baby  a  j^ear 
old.  The  temperature  of  the  water  should  not  be  guessed  at,  but 
tested  with  a  thermometer,  though  in  an  emergency  the  nurse 
may  safely  use  water  that  feels  comfortably  warm  to  her  elbow. 

It  is  a  good  plan  to  lay  a  folded  towel  in  the  bottom  of  the 
tub,  before  beginning,  as  babies  are  often  frightened  by  coming 
in  contact  with  the  hard  surface. 

The  nurse  should  wear  a  waterproof  apron,  covered  with  one 
of  flannel  over  which  is  laid  a  soft  towel  until  the  bath  is  fin- 


465 


466  OBSTETRICAL  NURSING 

ished,  when  it  is  slipped  out,  leaving  the  dry  flannel  apron  to 
wrap  about  the  baby.  She  should  wash  her  hands  thoroughly 
with  hot  water  and  soap ;  sit  squarely,  with  her  knees  together, 
in  a  chair  without  arms;  take  the  baby  in  her  lap  and  undress 
him  under  a  blanket. 

In  order  that  the  bath  may  be  given  deftly  and  quickly,  it  is  a 
good  plan  to  give  the  different  parts  in  the  same  order  every  day, 
for  practice  makes  perfect. 

It  is  usually  a  routine  to  weigh  the  baby  every  morning,  dur- 
ing the  first  two  or  three  weeks  and  once  or  twice  a  week  after- 
wards. Premature  babies  and  those  who  are  very  frail  are 
weighed  at  longer  intervals  because  of  the  inadvisability  of  dis- 
turbing them  so  often.  The  baby  is  undressed  for  his  bath, 
wrapped  in  a  blanket,  and  laid  in  the  scoop  or  basket  of  a  beam 
scale  (Fig.  153)  and  a  note  made  of  tlie  entire  weight,  for  if  he 
is  placed  in  the  scales  without  protection  he  is  likely  to  be  chilled 
and  frightened.  The  weight  of  the  blanket  is  ascertained  sep- 
arately and  deducted  from  the  total  thus  giving  the  baby 's  exact 
weight. 

The  eyes  should  be  bathed  first,  with  pledgets  of  sterile  cot- 
ton dipped  in  warm  boracic  acid  solution,  each  pledget  being 
used  but  once.  To  prevent  the  solution  from  running  from  one 
eye  into  the  other,  the  baby 's  head  is  turned  slightly  to  one  side 
and  the  lower  eye  wiped  gently  from  the  nose  outward.  The  lids 
may  then  be  separated  by  placing  one  thumb  below  the  brow  and 
lifting  it  slightly,  and  the  eye  flushed  with  a  gentle  stream  by 
squeezing  a  freshly  soaked  pledget  just  above  it.  The  head  is 
turned  to  the  other  side  and  the  eye  on  that  side  bathed  in  like 
manner. 

The  mouth  is  swabbed  out  very  gently  with  boric-soaked  cot- 
ton wrapped  about  the  tip  of  the  little  finger,  care  being  taken 
not  to  abrade  the  delicate  mucous  lining.  The  nostrils  are 
cleaned  with  little  spirals  of  cotton  dipped  in  liquid  petrolatum 
or  olive  oil. 

The  face  is  then  washed  with  warm  water,  no  soap,  and  patted 
dry.  The  scalp,  neck  and  ears  are  washed  with  soap  and  water 
and  thoroughly  dried  by  patting  and  wiping  gently  in  the 
creases.    The  body  should  then  be  well  soaped,  with  the  nurse's 


NUESING  CARE  OF  AVERAGE  NEW-BORN  BABY     467 

hand,  only  one  part  being  exposed  at  a  time,  to  avoid  chilling. 
To  place  the  baby  in  the  tub  the  nurse  may  slip  her  left  hand 
under  his  head  in  such  a  way  that  his  head  will  rest  upon  her 
wrist,  her  fingers  support  his  shoulders  and  her  thumb  curve 
over  and  hold  the  upper  part  of  his  arm.  She  may  then  grasp 
his  ankles  with  her  riglit  hand  and  lower  the  little  body  into  the 
water,  feet  first.  If  his  nvm  and  siiouhler  are  firmly  held  and 
supported  by  tlic  left  hand  it  is  an  easy  matter  to  steady  the 
entire  body  and  keep  the  baby's  head  out  of  the  water  while 
giving  the  bath  Avith  the  ri^dit  hand.     (Fig.  154.)     The  new  baby 


Fig.  154. — Method  of  supporting  baby 's  head  above  water  while  giving 
tub  bath. 

is  not  usually  kept  in  the  tub  for  more  than  two  or  three  minutes, 
but  when  he  is  three  or  four  months  old  he  may  stay  in  for  five 
minutes  and  still  longer  as  he  grows  older. 

Hot  water  should  not  be  poured  into  the  bath  after  the  baby 
has  been  placed  in  it  but  cold  water  is  often  added,  for  a  three 
or  four  months  old  baby,  or  the  warm  bath  folloAved  by  a  quick 
sponge  with  cold  water.  The  little  body  is  quickly  patted  dry 
and  rubbed  briskly  with  the  palm  of  the  nurse's  hand;  the  legs 
and  arms  stroked  toward  the  body ;  the  back  from  the  neck  down- 
ward and  the  chest  and  abdomen  with  a  circular  motion.  Babies 
who  react  well  to  cold  baths  are  benefited  bv  them  but  such 


468 


OBSTETRICAL  NURSING 


"toughening"  methods  have  to  be  tempered  to  the  resistance  of 
the  individual  baby  and  are  employed  only  under  the  supervi- 
sion of  the  doctor. 


Fig.  155. — Prcjiaration  for  circumcision.  (From  photograph  taken  at 
The  Cleveland  Maternity  Hospital,  with  description,  by  courtesy  of  Miss 
MacDonald.) 


On  TaMe  at  Left: 

Basin  of  sterile  water. 
3  sterile  towels. 
12    small   sponges. 
6  cotton  pledgets. 
1  inch  gauze  bandage. 
Tube    of    00    plain    catgut    with 
small   needle. 

Stand  at  Eight  : 

Large  basin  of  sterile  water. 

For  Baby: 

Brandy,   1    dram. 
Sterile  water,  6  drams. 
Sugar,  %  dram. 

One  nurse  holds  the  baby  by  his  knees  with  his  hands  under  her  arms. 
The  second  nurse  begins  the  anesthetic,  three  minutes  before  doctor  begins 
to  operate,  by  dropping  brandy  and  water  on  small  piece  of  sterile  cotton 
in  gauze  in  baby 's  mouth. 

The  genitals  should  be  bathed  and  dried  with  care ;  inspected 
daily  and  any  abnormality  reported  to  the  doctor.  It  is  not  un- 
common for  girl  babies  to  have  a  slight  bloody  discharge  from 
the  vagina.     This  is  unimportant  and  soon  disappears,  but  a 


Needle  holder. 

2   small  hemostats. 

Curved  Kelly  clamp. 

Sharp  pointed  curved   scissors. 

Blunt  dissector. 

Mouth  tooth  forceps. 


In  sterile  medicine  glass  with 

dropper. 
Used  for  anesthetic. 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     469 

purulent  discharge  is  likely  to  be  an  evidence  of  gonorrheal  vag- 
initis. It  is  routine  in  many  hospitals  to  retract  the  foreskin  of 
male  babies  every  morning  at  the  time  of  the  bath  by  rubbing 
it  back  with  gauze  or  cotton,  taking  pains  that  it  is  again  pulled 
forward  into  the  original  position  after  the  part  underneath  has 
been  bathed  with  boracic  acid  solution.  If  retraction  is  im- 
possible after  several  successive  daily  attempts,  the  baby  is  not 
infrequently  circumcised.     (Figs.  155,  156.) 

When  the  entire  body,  including  creases  and  folds,  has  been 


Fig.  156. — Baby  in  Fig.  155  draped  with  sterile  sheet. 


patted  quite  dry,  it  may  be  dusted  with  an  unscented  talcum 
powder,  but  this  powdering  must  not  be  resorted  to  as  an  aid 
in  drying  the  skin.  In  order  to  prevent  chafing,  the  buttocks 
and  thighs  should  be  wiped  clean  with  oil  or  bathed  with  warm 
water,  no  soap,  patted  dry  and  powdered  or  oiled  each  time  that 
the  diaper  is  changed. 

If  the  first  bath  is  a  tub  bath  the  cord  is  dressed  after  the 
baby  is  dried  and  powdered.  The  form  and  method  of  cord 
dressings  vary  somewhat  with  different  doctors  but  in  practically 
all  instances  the  dressings  are  sterile,  to  prevent  infection,  and 
porous  in  order  that  air  may  gain  access  to  the  cord  and  promote 


470 


OBSTETRICAL  NURSING 


the  drying,  separating  process.  The  dressing  itself  may  consist 
of  dry,  sterile  gauze  or  gauze  wet  with  alcohol,  applied  to  the 
cord  in  the  manner  of  a  finger  bandage  (Fig.  157)  ;  or  it  may 
consist  of  squares  of  sterile  gauze  or  muslin  with  holes  in  the 
centres  to  fit  around  the  cord,  and  dusted  with  some  such  powder 


Fig.  157. — Cord  stump  dressed  with  dry  sterile  gauze.      (From  photo- 
graph taken  at  .lohns  Hopkins  Hospital.) 

as  boric  acid,  bismuth  or  salicylic  acid  and  starch.  These 
squares  are  folded  about  the  cord  stump  which  is  laid  over  on 
the  abdomen,  being  directed  upward  to  prevent  its  being  wet 
with  urine.  A  gauze  sponge  is  placed  over  the  dressing  and  the 
binder  applied  with  firm,  even  pressure,  but  not  tightly,  and 
sewed  on  or  held  in  place  with  safety  pins.     (Fig.  158.)     The 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     471 

cord  dressing  is  not  removed  until  the  cord  separates,  unless  it 
is  wet  or  soiled,  but  as  a  rule  the  band  is  removed  every  morning 
at  the  time  of  the  bath,  or  whenever  it  is  soiled. 

After  the  band  has  been  applied  the  warmed  shirt,  diaper, 
petticoat  and  dress  are  put  on,  with  the  fewest  possible  motions, 


Fig.  158. — Flannel  band  applied  over  cord  dressing. 

and  the  baby's  hair  brushed  upward  from  the  neck  and  back 
from  his  forehead.  He  should  be  wrapped  in  a  small  blanket, 
fed  and  laid  quietly  in  his  crib  to  sleep.  If  his  hands  and  feet 
are  cold  a  hot-water  bottle  at  125°  F.  with  a  flannel  cover,  may 
be  placed  beside  him. 


472  OBSTETRICAL  NURSING 

When  the  baby  is  made  ready  for  the  night  he  may  have 
either  a  sponge  l)ath  or  simply  have  his  face  and  hands  sponged 
with  warm  water,  according  to  the  wishes  of  the  doctor.  The 
clothing  which  the  bab}'  has  worn  during  the  day  should  be  re- 
placed by  an  entirely  fresh  outfit.  The  day  and  night  clothing 
may  be  worn  more  than  once,  if  clean  and  if  aired  between  times, 
but  it  is  better  jiot  to  have  the  baby  wear  the  same  clothes  day 
and  night. 

Clothes.  The  baby's  clothes  may  play  an  important  part 
in  promoting  liis  well-being,  and  to  accomplish  this  they  must 
be  warm,  light-weight,  soft  and  porous.  They  should  be  simple ; 
fit  smoothly  and  be  loose  enough  and  short  enough  to  permit  the 
baby  to  move  unhampered.  In  order  that  his  body  may  be  kept 
at  an  even  temperature  their  weight  must  always  be  adjusted 
to  the  needs  of  the  moment.  The  general  tendency  is  to  dress 
the  baby  too  warmly,  as  a  result  of  which  he  perspires ;  is  listless, 
pale,  fretful ;  sleeps  badly ;  is  susceptible  to  colds  and  other  infec- 
tions and  has  poor  recuperative  powers.  His  digestion  is  likelj' 
to  be  deranged  and  he  may  have  prickly  heat.  On  the  other 
hand,  if  the  baby  is  not  dressed  warmly  enough  his  hands  and 
feet  will  be  cold  and  his  lips  blue ;  he  will  cry  from  discomfort 
and  the  general  result  may  be  lowered  vitality  and  disturbed 
digestion.  If  the  baby's  clothes  are  not  comfortable,  if  they  pull 
and  drag  or  have  tight  bands,  he  will  be  fretful  and  restless, 
with  disturbed  sleep  and  digestion  in  consequence. 

The  little  wardrobe  will  be  entirely  adequate,  under  ordinary 
conditions,  if  it  consists  of  shirts,  bands,  diapers,  flannel  petti- 
coats, dresses,  flannel  wrappers  and  sacques  with  a  cap  and  cloak 
for  extra  warmth  during  in-  or  out-door  airing.     (Fig.  159.) 

The  shirts  should  have  long  sleeves  and  high  necks;  they 
should  open  all  the  way  dowai  the  front  and  come  well  down  over 
the  hips.  During  the  cold  months  they  should  be  of  silk,  silk 
and  wool  or  cotton  and  wool,  as  all  wool  shirts  are  usually  too 
warm,  and  during  the  summer  months  they  should  be  of  all 
cotton  and  very  thin.  Size  No,  2  is  the  best  size  to  start  with  as 
the  smaller  size  is  soon  outgrown. 

The  first  bands  usually  consist  of  strips  of  all  wool  or  cotton 
and  wool  flannel  about  six  inches  wide  and  eighteen  or  twenty 


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474 


OBSTETRICAL  NURSING 


inches  long,  torn  across  the  width  of  the  material  and  not 
hemmed.  This  straight  binder  is  worn  until  the  cord  dressing 
is  discontinued,  when  it  is  replaced  by  a  knitted  band  with 
shoulder  straps.    If  the  cord  dressing  is  held  in  place  by  a  gauze 


Fig.   160. — Appearance   of  properly  adjusted   diaper   which   has   been 
folded  diagonally. 

binder,  the  knitted  band  with  straps  is  used  from  the  beginning. 
Whether  the  binder  be  flannel  or  gauze,  it  must  be  applied  firmly 
and  with  even  pressure,  but  not  tight.  It  is  a  mistake  to  think 
that  a  tight  band  strengthens  the  baby's  abdominal  muscles  for 


,r*MSi>^- 


Fig.   161. — Appearance   of   properly   adjusted   diaper  which   has   been 
folded  longitudinally. 

it  has  the  opposite  tendency.     A  tight  band  may  give  pain  or 
discomfort  and  even  cause  colic  or  vomiting. 

The  knitted  band  is  usually  worn  for  three  or  four  months, 
particularly  in  cold  weather,  to  provide  a  little  extra  warmth 


NURSING  CARE  OP  AVERAGE  NEW-BORN  BABY     475 

over  the  abdomen.  Thin,  delicate  babies  sometimes  need  this 
band  for  a  year  or  more. 

The  diapers  should  be  of  soft,  absorbent  material,  of  a  loose 
weave,  such  as  cheese  cloth,  bird's-eye,  stockinette,  thin  Turk- 
ish towelling  or  outing  flannel ;  should  be  18  or  20  inches  square 
and  hemmed.  There  are  two  methods  of  putting  on  the  diaper. 
One  is  to  fold  the  square  diagonally  and  bring  the  diagonal  fold 
around  the  baby's  waist.  One  of  the  lower  corners  is  drawn  up 
between  the  thighs,  the  two  corners  from  the  sides  brought  over 
this  and  the  fourth  corner  brought  up  over  tiiese  and  all  pinned 
securely  with  a  safety  pin.  (Fig.  160.)  Small  safety  pins  hold 
the  margins  together  above  the  knees.  The  other  method  is  to 
fold  the  diaper  straight  through  the  centre,  forming  a  rectangle, 
twuce  as  long  as  it  is  wide;  lay  the  baby  on  it  lengthwise,  draw 
it  up  betw^een  his  thighs  and  pin  it  on  each  side  at  the  waist  line 
and  above  the  knees.     (Fig.  161.) 

In  either  case  the  diaper  must  be  put  on  smoothly  and  care 
taken  to  avoid  forming  a  thick  pad  between  the  thighs  as  this 
will  tend  to  curve  the  bones  of  the  legs.  Squares  of  soft,  ab- 
sorbent material,  which  may  be  burned,  placed  inside  the  diapers, 
will  greatly  facilitate  the  laundry  work.  In  some  hospitals  a 
very  soft  absorbent  paper  is  used  for  this  purpose,  sometimes 
being  covered  with  gauze. 

The  baby's  diaper  should  be  changed  whenever  it  is  wet  or 
soiled,  for  in  addition  to  making  him  restless  and  fretful  for  the 
time  being,  the  skin  about  the  thighs  and  buttocks  will  grow  red 
and  chafed  if  he  is  allowed  to  wear  wet  diapers.  Wet  diapers 
should  not  be  dried  and  used  again  but  washed  with  a  mild  soap, 
boiled  and  whenever  possible,  dried  in  the  open-air  and  sun- 
shine. 

All  of  this  makes  it  apparent  that  the  regular  use  of  water- 
proof protectors  cannot  l)e  justified  since  tiie  chief  reason  for 
putting  them  on  a  baby  is  to  avoid  tiie  necessity  of  changing 
his  diaper  as  soon  as  it  is  wet.  Under  special  circumstances  such 
as  a  drive,  a  short  journey  or  visit  the  diaper  may  be  protected 
by  water-proof  drawers.  Their  habitual  use  saves  work  for  the 
nurse  but  makes  the  baby  uncomfortable  and  unhappy. 

The  petticoat  should  be  of  light-weight,  cotton  and  wool  flan- 


476  OBSTETRICAL  NURSING 

nel,  cut  after  the  familiar  Gertrude  pattern  and  hang  straight 
from  the  shoulders.  It  may  fasten  in  the  back  or  on  the  shoul- 
ders, with  small  buttons  or  with  tapes.  Tapes  are  often  objected 
to  on  the  ground  that  the  baby  tangles  them  up  with  his  fingers, 
which  annoys  him,  and  often  puts  them  in  his  mouth.  This 
petticoat  is  worn  practically  all  the  time,  except  during  very 
warm  weather. 

The  slips  or  dresses  are  most  satisfactory  if  cut  after  the 
same  pattern  as  the  petticoat,  with  the  addition  of  sleeves  which 
may  be  set  in,  or  of  the  kimono  style.  The  dresses  serve  chiefly 
to  keep  the  petticoats  clean  and  make  the  baby  look  dainty,  and 
are  accordingly  made  of  soft  cotton  material  such  as  nainsook, 
cambric  or  lawn.  In  summer,  it  is  true,  the  petticoat  is  often  dis- 
carded and  the  thin  slip  put  on  over  the  shirt  and  diaper. 

The  night  gowns  are  made  like  the  dresses  but  are  of  soft 
flannel  or  stockinette,  in  cold  weather,  and  tape  is  often  run 
through  the  hems  in  order  that  they  may  be  drawn  up,  bag- 
fashion,  to  keep  the  baby's  feet  warm.  During  very  warm 
weather  the  baby  sleeps  in  a  thin  cotton  slip. 

In  addition  to  these  garments  there  are  many  times  when  a 
soft  little  sacque  or  wrapper  is  used  to  keep  the  baby  warm,  and 
one  or  two  flannel  squares  (one  yard),  to  wrap  around  him  when 
he  is  carried  about  the  house  are  practically  indispensable. 

The  petticoats,  dresses  and  night  gowns  are  cut  about  twenty- 
seven  inches  long  and  many  doctors  feel  that  thej^  offer  sufficient 
protection  for  the  feet  of  the  average  baby  to  make  stockings  un- 
necessary until  he  is  from  four  to  six  months  old.  The  skirts 
may  then  be  shortened  to  ankle  length  and  stockings  added  to 
the  little  wardrobe.  Some  doctors  think  it  wiser  to  put  knitted 
socks  or  part  wool  stockings  on  the  new  baby  particularly  if  he 
is  born  during  cold  weather. 

When  the  baby  begins  to  creep,  he  should  wear  soft  soled 
shoes,  part  wool  stockings  in  cold  weather  and  thin  cotton  or  silk 
ones  during  the  summer,  and  firm  but  flexible  soled  shoes  as  soon 
as  he  tries  to  stand  alone  or  to  walk. 

During  the  first  month  or  two,  the  baby  scarcely  needs  spe- 
cial clothing  for  out-door  wear,  as  he  may  be  warmly  wrapped  in 
one  of  the  flannel  squares  by  being  placed  on  it  diagonally,  the 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     477 

upper  corner  folded  about  his  head  to  form  a  hood  and  held  under 
his  chin  with  a  safety  pin.  The  corners  on  the  siih's  are  folded 
about  his  shouhh'rs,  tlie  h)wer  one  br()Uf>iit  up  over  his  feet  and 
limbs  and  tlic  achlilional  hhtiikcts  tucked  in  over  all.  \\\\\  as  he 
grows  older  and  moves  about  in  his  carriage,  lie  will  need  a  cap 
and  cloak  or  wrap  with  hood  attached.  In  cold  weather  the  cap 
should  be  knitted  or  wool  lined  and  tiie  cloak  of  soft  woolen 
material  or  wool  lined.  In  moderate  weather  the  cap  may  be 
of  one  thickness  of  cotton  or  silk,  or  very  light  flannel,  wliile  on 
very  warm  days  he  will  need  no  head  covering. 

To  sum  up:  The  baby's  clothes  should  be  simple  in  design, 
hang  from  the  shoulders,  fit  smoothly  but  loosely  and  have  no 
constricting  bands;  they  should  be  soft,  light  and  porous,  their 
warmth  always  adjusted  to  the  immediate  temperature  so  that 
the  baby  will  be  protected  from  being  either  chilled  or  over- 
heated.    And  his  clothing  must  always  be  clean  and  drj'. 

Fresh  Air.  An  abundance  of  fresh  air  is  one  of  the  baby's 
greatest  needs  as  it  increases  his  resistance  and  recuperative 
powers,  improves  his  appetite  and  aids  digestion.  In  general, 
the  more  the  baby  is  in  the  open  air  and  the  more  fresh  air  he 
has  while  in  the  house,  the  better. 

The  two  factors  which  must  be  considered  in  supplying  the 
baby  with  fresh  air  are  the  condition  and  vigor  of  the  baby  him- 
self and  the  immediate  temperature  and  state  of  the  weather. 
His  age  and  the  season  of  the  year  can  be  only  partial  guides  be- 
cause of  the  difference  betw'een  individual  babies  of  the  same  age 
and  the  variations  in  temperature,  winds  and  moisture  during 
any  one  season. 

The  air  of  the  room  which  the  baby  occupies  should  be 
changing  constantly  in  order  that  it  may  always  be  fresh,  but  the 
temperature  should  be  equable  and  the  baby  protected  from 
drafts.  As  the  tendency  here,  as  with  the  baby's  clothes,  is 
toward  overheating,  the  nurse  will  do  well  to  remember  that  the 
new  baby  who  lies  covered  up  in  his  crib,  may  usually  be  kept 
in  a  colder  room  than  is  advisable  for  an  older  one  who  is  creep- 
ing or  walking  about. 

During  cold  weather  the  baby's  bed  should  not  be  directly 
in  front  of  an  open  window  and  he  should  be  protected  from 


478  OBSTETRICAL  NURSING 

direct  currents  of  cold  air  by  a  sheet  hung  over  the  head  and 
side  of  his  crib.     (See  Fig.  153.) 

Two  or  three  times  daily,  while  the  baby  is  out  of  the  room, 
the  windows  should  be  opened  wide  to  air  the  room  thoroughlj^, 
one  of  these  airings  being  just  before  the  baby  is  put  to  bed  for 
the  night. 

The  usual  instructions  concerning  the  temperature  of  the 
nursery  are  to  keep  it  from  68°  F.  to  70°  F.  during  the  day  and 
about  65°  F.  at  night,  during  the  first  three  months  and  lower 
it  gradually  to  64°  F.  during  the  day  and  about  55°  F.  at  night 
as  the  baby  grows  older.  It  is  customary  to  begin  to  open  the 
nursery  window  at  night  when  the  baby  is  three  or  four  months 
old,  if  he  is  well  and  the  temperature  is  above  freezing. 

In  planning  to  take  the  baby  out-of-doors  it  is  wiser,  as  a  rule, 
to  begin  with  the  indoor  airing  when  he  is  about  a  month  old, 
except,  of  course,  during  the  moderate  or  mild  months  of  the 
year,  when  he  is  taken  out  at  once.  If  the  weather  is  cold,  the 
baby  may  be  protected  with  extra  wraps  and  carried  in  the 
nurse's  arms,  into  a  room  in  which  the  windows  are  open  and 
kept  there  for  fifteen  or  twenty  minutes.  This  indoor  airing  is 
increased  by  being  gradually  lengthened  to  two  or  three  hours 
and  by  having  the  windows  opened  wider  and  wider.  By  the 
time  he  is  two  or  three  months  old  he  is  taken  out  of  doors  on 
clear,  bright  days,  the  best  time  being  between  ten  and  three 
o'clock,  when  the  sun  is  high.  If  he  is  carried  in  the  nurse's 
arms  at  first  the  warmth  of  her  body  serves  as  a  protection  and 
helps  to  accustom  him  to  the  out-of-door  life,  .when  he  spends 
a  good  deal  of  his  time  out  of  doors  in  his  carriage. 

On  windy,  stormy  days  or  when  there  is  melting  snow  on 
the  ground  the  baby  may  be  given  his  airing  on  a  protected 
porch  or  in  a  room  with  the  windows  open.  He  is  not  usually 
taken  out  if  the  temperature  is  below  freezing  until  the  third  or 
fourth  month.  After  this  time  the  average  baby  is  taken  out 
when  the  temperature  is  not  lower  than  20°  F. 

When  the  baby  is  dressed  in  his  extra  wraps  he  must  be  taken 
out  of  doors  or  the  windows  opened  immediately,  for  otherwise 
he  will  become  overheated  and  be  in  danger  of  chilling  when 
taken  into  the  colder  air. 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     479 

Warm  hands  and  feet,  a  good  color  and  the  baby's  tendency 
to  sleep  most  of  the  time  while  out-of-doors  are  evidences  of  his 
being  adequately  clothed  for  his  airing,  while  the  reverse  is  true 
if  he  is  not  warm  enough. 

A  robust  baby  who  has  been  gradually  accustomed  to  l)eing 
out-of-doors  during  the  day  will  usually  be  much  benefited  by 
sleeping  out  at  night.  But  he  must  be  protected  from  winds  and 
his  clothing  so  arranged  that  he  cannot  be  chilled.  Kiutted  or 
flannel  sleeping  garments  or  sleeping  bags  (See  Fig.  159)  are 


I 


^ 


Fig.  162. — Sutton  poncho  which  keeps  the  baby  warm  by  covering  all 
but  his  head.  The  insert  shows  slit  for  his  head.  The  regular  bedding  is 
temporarily  turned  back  in  this  picture.  (From  photograph  taken  at 
Bellevue  Hospital.) 

valuable  and  in  addition,  the  blankets  which  cover  the  baby 
should  be  securely  pinned  to  the  mattress  with  safety  pins  and 
tucked  well  under  it  at  the  sides  and  foot.  The  baby  should 
wear  a  warm  cap  and  the  bed  should  be  warmed  before  he  is  put 
into  it.  Or  better  still,  he  may  be  dressed  for  the  night,  put 'to 
bed  in  a  warm  room  and  the  crib  then  moved  out  on  the  sleeping- 
porch. 

An  excellent  device  for  protecting  the  baby's  arms  and  chest 


480  OBSTETRICAL  NURSING 

and  keeping  him  generally  well  covered  is  the  poncho  (Fig.  162) 
devised  by  Dr.  Lncy  Porter  Sntton  of  Bellevue  Hospital.  The 
poncho  is  a  rectangle  made  of  flannel,  outing  flannel  or  an  old 
blanket  and  cut  large  enough  to  tuck  well  under  the  liead  and 
sides  of  the  mattress  and  extend  below  the  babj^'s  feet.  The 
baby's  head  slips  through  an  opening,  which  is  almost  a  right- 
angled  slit,  near  the  centre  of  the  poncho  and  about  20  inches 
from  the  top.  The  slit  is  firmly  bound  and  provided  with  tapes 
to  tie  it  together  after  the  baby  is  put  in.  The  poncho  should  be 
put  on  loosely  enough  to  permit  the  baby  to  move  about  at  will 
beneath  it.  After  it  is  adjusted  the  bed  is  made  up  as  usual 
with  additional  blankets. 

Under  all  conditions  the  baby's  airings  must  be  increased 
gradually,  both  as  to  lowering  the  temperature  and  lengthening 
the  time,  and  always  adjusted  to  the  vigor  and  reaction  of  the 
individual  baby.  He  must  be  warm,  but  not  too  warm ;  he  must 
be  protected  from  wind  and  dust,  and  his  eyes  shielded  from 
glare  and  from  flickering  light  such  as  may  be  caused  by  a  tree 
in  a  light  breeze. 

Exercise.  Although  the  baby  should  not  be  handled  unnec- 
essarily nor  tossed  about  and  played  with  by  friends  and  rela- 
tives, it  is  important  that  his  muscular  development  be  promoted 
by  regular  and  carefully  planned  exercise.  It  is  usually  consid- 
ered best  for  the  baby  to  lie  quiet  and  undisturbed  in  his  crib 
most  of  the  time  during  the  first  three  or  four  weeks.  Dr.  Grif- 
fith begins  the  baby's  exercise  about  that  time  by  having  the 
nurse  take  him  in  her  arms  on  a  pillow  and  carry  him  about  for 
a  few  moments,  several  times  daily.  After  a  week  or  two  of  this 
form  of  exercise,  the  nurse  carries  the  baby  without  a  pillow 
but  supports  his  head  and  back. 

The  position  of  the  baby's  body  is  changed  by  being  carried 
about  in  this  way,  while  the  movement  of  the  nurse  as  she  walks 
about  causes  a  certain  amount  of  motion  of  the  baby's  muscles, 
constituting  a  gentle  exercise. 

This  exercise,  in  the  form  of  picking  up  and  carrying  about 
is  regarded  by  many  pediatricians  as  of  great  importance.  There 
is  a  possibility  that  lack  of  this  form  of  "mothering"  is  one  rea- 
son why  babies  in  hospital  practice  sometimes  fail  to  progress 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     481 

as  they  should.  Certainly  lying  too  long  in  one  position  is 
harmful.  The  nurse  should  carry  the  baby  first  on  one  arm  and 
then  on  the  other  in  order  that  both  sides  of  his  body  may  be 
equally  exercised.  By  the  third  or  fourth  month  he  sits  up  in 
her  arms  as  she  carries  him  about,  and  he  may  be  placed  on  the 
outside  of  his  crib  coverings  for  a  little  while  every  day,  to  kick 
and  struggle  at  will.  His  skirts  should  be  rolled  up  under  his 
shoulders,  or  removed  entirely,  to  leave  his  legs  quite  free,  care 
being  taken  that  the  room  is  warm  and  that  he  has  on  stockings. 


Fig.  163. — A  comfortable  position  for  the  baby  being  trained  to  use 
chamber. 


By  about  the  sixth  month  he  will  usually  begin  to  make  an 
effort  to  creep,  if  turned  over  on  his  stomach  and  helped  a  little, 
and  he  may  be  propped  up  in  the  sitting  position,  in  his  crib, 
for  a  few  moments  every  day.  As  he  gives  evidence  of  having 
enough  energy  to  creep  farther  than  the  size  of  his  crib  permits, 
he  may  be  put  into  a  creeping-pen,  or  upon  the  floor  under  cer- 
tain conditions.  It  must  be  remembered  that  the  floor  is  likely 
to  be  cold,  drafty  and  dusty.  The  nurse  must  assure  herself, 
therefore,  that  the  floor  is  warm;  must  cut  off  all  drafts  and 
spread  a  clean  sheet  or  quilt  on  the  floor  before  the  baby  is  put 
down  to  creep.  When  the  sheet  is  taken  up,  it  is  folded  with  the 
upper  surface  inside  in  order  that  when  it  is  again  put  down  the 


482  OBSTETRICAL  NURSING 

baby  will  play  on  the  clean  side  and  not  on  the  side  that  has  been 
next  the  floor. 

A  ereeping-pen  or  cariole  or  some  such  provision  is  often  more 
satisfactory  than  the  floor,  consisting  as  it  does  of  a  railed-in 
platform  raised  about  six  or  eight  inches  from  the  floor. 

The  suggestions  for  exercise,  like  those  for  the  baby's  airing, 
must  be  very  general  since  it  must  always  be  adjusted  to  the 
powers  of  the  individual  baby  and  under  the  doctor 's  supervision. 

TRAINING  THE  BABY 

Bowels.  It  is  possible  to  train  even  a  very  young  baby  to 
have  regular  daily  bowel  movements;  this  training  should  be 
started  when  the  baby  is  about  a  month  old.  At  the  same  hour 
each  day  he  may  be  laid  on  a  padded  table,  or  taken  in  the 
nurse 's  lap,  a  small  basin  being  placed  against  or  under  the  but- 
tocks, and  a  soap  stick  introduced  an  inch  or  two  into  the  rec- 
tum and  moved  gently  in  and  out.  This  slight  irritation  will 
usually  result  in  the  baby's  emptying  his  bowels  almost  immedi- 
ately. Or  he  may  be  held  on  a  small  chamber  on  the  nurse's 
lap,  in  a  comfortable  reclining  position  (Fig.  163)  or  with  his 
back  supported  against  her  chest,  and  the  desire  to  empty  the 
bowels  stimulated  by  using  the  soap  stick. 

It  is  of  greatest  importance  that  the  position  and  method 
which  are  adopted,  be  employed  at  exactly  the  same  time  each 
day.  If  this  is  done,  and  the  baby  is  being  properly  fed,  it  will 
usually  be  found  that,  before  he  is  many  months  old,  his  bowels 
will  move  freely  and  regularly  without  the  stimulation  of  the 
soap  stick  and  only  when  he  is  resting  on  the  small  basin  or 
chamber.  This  establishment  of  a  regular  bowel  movement  not 
only  simplifies  the  laundry  work  but  is  of  great  moment  to  the 
baby's  health. 

Thumb-Sucking.  It  is  scarcely  necessary  to  remind  a  nurse 
that  the  baby  must  not  be  allowed  to  suck  on  an  empty  bottle  or 
a  pacifier  nor  be  permitted  to  suck  his  thumb.  The  habits  are 
very  dirty  and  help  to  spread  infections.  The  baby  may  swallow 
air  while  practicing  them,  with  colic  as  a  result,  and  he  may  so 
deform  the  shape  of  his  upper  jaw  that,  later  in  life,  the  upper 
and  lower  teeth  will  not  meet  as  they  should  when  he  masticates ; 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     483 

his  front  teeth  may  protrude  in  a  disfiguring  manner;  and  by 
narrowing  and  elongating  the  roof  of  his  mouth  the  structure 
of  the  air  passages  is  altered,  with  respiratory  troubles  and  ade- 
noids as  a  frequent  consequence.  Thumb-sucking  may  be  pre- 
vented by  the  simple  procedure  of  putting  stiff  cuffs  on  the 
baby's  elbows  (Fig.  164)  which  make  it  impossible  for  him  to 
reach  his  mouth  with  his  thumb.  These  cuffs  may  be  made  by 
covering  pieces  of  cardboard  with  muslin  and  attaching  tapes 
with  which  to  tie  them  on  the  baby's  arms.    His  hands  may  be 


Fig.  164. — Stiff  cuffs  to  prevent  thumb  sucking. 
taken  at  Johns  Hopkins  Hospital.) 


(From  photograph 


put  into  celluloid  or  aluminum  mitts,  or  little  bags  made  of  stiff, 
heavy  material,  which  in  turn  are  tied  to  his  wrists,  or  his  sleeves 
may  be  drawn  down  over  his  hands  and  sewed  or  pinned  with 
safety  pins.  It  should  be  borne  in  mind  that  a  baby  sometimes 
sucks  his  thumb  because  he  is  hungry  or  thirsty  and  gives  up  the 
practice  when  his  food  is  increased  or  when  he  is  regularly  given 
water  to  drink. 

Eax  Pulling  is  not  uncommon  among  young  babies  and  if 
allowed  to  continue  a  long,  mis-shapen  ear  may  result.  This  may 
be  prevented  by  using  a  thin,  close  fitting  cap  which  ties  under 


484 


OBSTETRICAL  NURSING 


the  chin,  or  by  using  the  same  kind  of  elbow  splints  as  for  thumb- 
sucking. 

Crying.  It  is  very  easy  to  allow  the  baby  to  develop  the 
crying  habit,  but  very  difficult  to  break  it  up.  A  baby  who  is 
properly  fed,  kept  dry  and  warm  but  not  too  warm,  and  whose 
clothes  are  comfortable  will  usually  cry  very  little  if  wisely 

handled.  But  a  baby  may  cry  be- 
cause he  is  hungry,  thirsty,  wet,  cold, 
over-heated,  sick  or  in  pain  or  simply 
because  he  wants  to  be  taken  up  and 
entertained  and  has  learned  that  the 
w^ay  to  realize  his  wish  is  to  cry.  By 
closely  observing  the  baby's  habits 
and  his  condition  the  nurse  will  usu- 
ally be  able  to  ascertain  the  cause  of 
the  crying.  Very  often  a  drink  of 
fairly  warm,  sterile  water  will  quiet 
him,  particularly  at  night.  But  both 
the  nurse  and  the  mother  should  re- 
frain from  taking  the  crying  baby  up 
and  carrying  him  or  holding  him 
when  it  is  discovered  that  this  atten- 
tion stops  his  crying.  Persistent  cry- 
ing should  always  be  reported  to  the 
doctor,  as  it  may  have  serious  significance. 

Ruminating.  Some  babies  have  the  habit,  called  "ruminat- 
ing," of  bringing  up  food;  chewing  it;  moving  it  about  and 
finally  rolling  it  out  of  their  mouths.  AltTiough  this  habit  has 
not  been  recognized  until  comparatively  recently,  it  is  now  be- 
lieved to  be  of  fairly  common  occurrence  and  often  mistaken  for 
vomiting.  It  is  seen  as  a  rule  in  precocious  babies  who  take 
more  interest  in  their  surroundings  than  the  average,  more 
placid  infant,  beginning  very  early  to  fix  their  attention  upon 
light,  sounds  and  moving  objects.  The  ruminator  begins  by 
bringing  up  a  small  amount  of  his  last  nourishment,  then  a  little 
more  and  a  little  more  until  finally  he  has  brought  up  nearly  or 
quite  all  of  it,  apparently  deriving  a  certain  amount  of  pleasure 
and  satisfaction  from  the  procedure.    Quite  obviously,  a  contin- 


FiG.  165. — Cap,  to  prevent 
ruminating.  (Devised  by 
Miss  Hammer.) 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     485 

uation  of  this  practice  results  in  undernourishment,  sometimes 
even  starvation,  since  the  baby  actually  retains  very  little  if  any 
of  his  food.  As  liquids  come  up  more  easily  than  solids,  the 
first  step  t()wai-(l  breaking  up  this  habit  is  usually  to  give  the  baby 
more  solid  and  concentrated  food  than  he  has  been  taking  and 
to  carry  him  about,  talk  to  him  and  entertain  him  for  about  an 
hour  after  feedings,  for  if  his  attention  is  otherwise  engaged,  he 


Fig.  166. — Runiinatiug  cap  applied.     (From  photograph  taken  at  Johns 
Hopkins  Hospital.) 

is  not  likely  to  ruminate.  Another  efficacious  measure  is  the  use 
of  a  cap  (See  Pig.  165)  so  constructed  and  tied  under  his  chin 
that  the  baby's  jaws  are  held  tightly  together  and  he  is  unable  to 
make  the  movements  which  are  necessary  to  rumination.  (Fig. 
166.) 

FEEDING  THE  BABY 
Proper  feeding  is  probably  the  most  decisive  single  factor  in 
the  routine  care  of  the  baby. 


486  OBSTETillCAL  NURSING 

In  order  that  the  food  be  satisfactory  it  must  be  not  only 
suitable  in  composition  for  the  individual  baby,  but  it  must  be 
clean,  fresh  and  at  the  right  temperature;  given  in  suitable 
amounts  and  at  suitable  and  regular  intervals;  it  must  be  given 
properly — not  too  fast  nor  too  slowly  and  it  must  be  given  under 
favorable  conditions. 

Moreover,  the  baby  himself  must  be  kept  in  a  general  condi- 
tion which  will  favor  the  digestion  and  assimilation  of  the  food 
that  is  given  to  him.  Fresh  air,  suitable  clothing,  an  even  body 
temperature,  gentle  handling,  proper  bathing,  regular  sleep, 
freedom  from  excitement,  fatigue  and  irritation,  all  promote  the 
baby's  ability  to  use  his  food  to  advantage.  Reverse  influences 
all  work  against  it. 

The  character,  amount  and  intervals  of  the  baby 's  feeding  are 
definitely  ordered  by  the  doctor,  but  the  many  factors  which  in- 
fluence the  baby's  nutrition  are  so  largely  a  matter  of  nursing 
that  the  nurse  has  grave  responsibilities  in  connection  with  his 
nourishment. 

After  other  conditions  have  been  made  favorable,  the  factors 
which  determine  the  character  of  the  baby's  food  are  the  kind 
and  amount  of  food  materials  which  are  needed  by  his  growing 
body  and  the  powers  of  his  digestive  organs.  If  he  is  given  less 
food  than  he  needs  at  each  stage  of  his  progress  he  will  not  be 
properly  nourished ;  but  if  he  is  given  food  materials  in  quan- 
tities, proportions  or  character  which  are  beyond  the  power  of 
his  immature  alimentaiy  tract  to  digest,  he  not  only  will  not  be 
properly  nourished  but  probably  will  be  made  ill. 

There  are  three  methods  of  nourishing  the  baby :  breast  feed- 
ing, artificial  feeding  and  a  combination  of  the  two,  termed 
mixed  or  supplementary  feeding. 

Breast  Feeding.  From  all  standpoints,  maternal  nursing 
under  normal  conditions  is  the  most  satisfactory  method  of  inf ani 
feeding.  If  the  breast  milk  is  suitable  it  meets  all  of  the  babj^'s 
requirements  and  the  proportion  and  character  of  its  constitu- 
ents are  exactly  suited  to  his  digestive  powers. 

In  order  that  the  nursing  be  entirely  satisfactory,  the  con- 
dition of  both  mother  and  baby  must  be  favorable  to  its  success. 
The  preparation  and  care  of  the  mother  have  been  described :  her 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     487 

general  condition  and  state  of  nutrition ;  the  care  and  condition 
of  her  nipples,  flat  or  retracted  nipples  being  brought  out  if 
possible,  and  if  not,  the  nursing  facilitated  by  the  use  of  a  shield. 
If  the  baby's  diaper  is  wet  or  soiled,  it  should  be  changed  before 
he  is  put  to  the  breast,  partly  to  make  him  comfortable  and  partly 
to  avoid  disturbing  him  after  his  feeding.    His  mouth  is  gently 


Fig.  167. — Proper  method  of  carrying  baby  to  support  head  and  back. 
(From  photograph  taken  at  Johns  Hopkins  Hospital.) 

swabbed  with  boric  soaked  cotton,  if  this  is  ordered,  he  is  wrapped 
in  a  little  blanket  and  carried  to  his  mother  dry  and  warm  and 
comfortable.  (Fig.  167.)  Although  nursing  is  an  instinct,  the 
baby  sometimes  has  to  learn  or  to  acquire  the  habit  which  is 
one  reason  for  putting  him  to  the  breast  during  those  first  two 
or  three  days  when  he  obtains  little  or  no  actual  food.  (See 
Chapter  XVI.)    As  he  expresses  the  milk  by  a  squeezing  and  sue- 


488  OBSTETRICAL  NURSING 

tion  made  possible  only  when  the  nipple  is  well  back  in  his 
mouth,  he  must  take  into  his  mouth  practically  the  entire  pig- 
mented area  which  surrounds  the  nipple.  To  do  this  he  lies  in 
the  curve  of  his  mother's  arm  as  she  turns  slightly  to  one  side, 
and  holds  her  breast  away  from  his  nostrils  in  order  that  he  may 
breathe  freely. 

Sometimes  even  when  other  conditions  are  favorable,  the 
baby  is  unable  to  nurse  because  of  some  physical  disability.  He 
may  be  too  feeble;  have  a  cleft  palate  or  find  suckling  painful 
because  of  an  abrasion  of  the  mucous  membrane  which  occurred 
when  his  mouth  was  bathed  just  after  birth.  The  manner  in 
which  the  baby  nurses,  therefore,  may  be  significant  and  should 
be  carefully  noted  and  described  to  the  doctor. 

There  is  a  difference  of  opinion  among  doctors  concerning 
the  interval  between  feedings  which  is  most  satisfactory.  Some 
have  the  baby  nurse  every  four  hours  and  others  every  three 
hours  during  the  early  months  of  life.  It  is  believed  by  some 
doctors  that  although  a  baby  who  is  fed  on  a  four-hour  schedule 
may  regain  his  birth  weight  more  slowly  than  the  baby  who  is 
fed  every  three  hours,  he  suffers  less  from  digestive  disturbances 
and  ultimately  makes  an  entirely  satisfactory  gain  in  weight. 
Another  point  in  favor  of  the  four-hour  interval  is  the  longer 
period  of  freedom  which  this  gives  to  the  mother  and  this  may 
influence  her  willingness  to  nurse  her  baby.  But  other  doctors, 
both  pediatricians  and  obstetricians,  feel  that  the  four-hour  in- 
terval is  too  long  for  most  babies. 

Whether  the  baby  shall  nurse  from  one  or  both  breasts  at  each 
feeding  is  another  moot  question.  Some  doctors  believe  that  the 
results  are  better  if  both  breasts  are  partially  emptied  at  each 
nursing,  while  others  feel  that  the  function  of  the  breasts  is  more 
satisfactorily  promoted  by  completely  emptying  one  breast  at  a 
time,  at  alternate  nursings.  Although  the  baby  should  pause 
every  four  or  five  minutes  to  prevent  his  nursing  too  rapidly, 
which  is  a  common  cause  of  colic,  neither  he  nor  his  mother 
shoul(f  be  allowed  to  sleep  during  the  nursing  periods.  When  he 
has  finished,  he  should  be  taken  up  very  gently  and  placed  in 
his  crib  and  left  to  sleep.  If  he  is  nursing  satisfactorily,  he  will 
be  sleepy  and  contented  after  nursing  and  will  sleep  for  two  or 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     489 

three  hours  afterwards;  he  will  seem  generally  good  humored 
and  comfortable  while  awake;  he  will  have  good  color;  gain 
weight  steadily  and  have  two  or  three  normal  bowel  movements 
daily.  The  normal  stool  in  breast  fed  babies  is  bright  yellow, 
smooth  and  with  no  evidences  of  undigested  food. 

If  he  is  not  being  adequately  nourished,  he  will  present  ex- 
actly the  opposite  picture,  in  some  or  all  of  these  respects.  He 
will  be  unwilling  to  stop  nursing  after  the  normal  length  of  time 
and  will  give  evidence  of  not  being  satisfied  when  taken  from 
his  mother.  He  may  be  listless  and  fretful  and  sleep  badly.  He 
will  not  gain  weight  as  he  should,  and  he  may  vomit  or  have 
colic  after  nursing. 

To  ascertain  whether  or  not  such  a  baby  is  getting  enough 
milk  it  is  customary  to  w^igh  him,  without  undressing  him, 
before  and  after  each  nursing.  Each  fluid  ounce  of  food  will  in- 
crease his  weight  one  ounce.  If  the  baby  is  not  getting  a  normal 
amount  of  milk  at  each  nursing  he  is  often  given  enough  modi- 
fied milk  after  each  meal  to  supply  the  deficit,  but  at  the  same 
time  an  effort  is  made  to  increase  the  supply  of  breast  milk  by 
improving  the  mother's  personal  hygiene. 

The  amount  which  the  baby  needs  at  each  feeding  varies,  not 
only  according  to  his  weight  and  age,  but  also  according  to  his 
vigor  and  activity,  and  must  always  be  figured  for  the  individual 
baby.  A  very  general  estimate  of  the  amount  taken  by  the  aver- 
age well  baby  at  each  feeding,  is  about  as  follows : 

First  week    li/^  to  2I/2  ounces 

Second    and   third    week 2       to  4  ounces 

Fourth  to  ninth  week 3       to  4i/^  ounces 

Tenth  week  to  fifth  month 3I/2  to  5  ounces 

Fifth  to  seventh  month 41/2  to  6i/^  ounces 

Seventh  to  twelfth  month 6^/2  to  9  ounces 

Artificial  Feeding.  There  is  no  entirely  adequate  substitute 
for  satisfactory  maternal  nursing,  and  any  other  food  that  is 
given  to  the  young  baby  is  at  best  a  makeshift.  Considering  the 
baby's  delicacy,  therefore,  and  his  urgent  needs,  no  pains  should 
be  spared  to  make  any  artificial  food  which  is  given  to  him  as  sat- 
isfactory as  possible.  In  preparing  and  giving  artificial  food 
it  must  be  borne  in  mind  that  normal  breast  milk : 


490  OBSTETRICAL  NURSING 

1.  Is  exactly  right  in  quantity,  quality  and  proportion. 

2.  Is  fresh,  clean  and  sweet. 

3.  Is  free  from  bacteria. 

4.  Tends  to  protect  the  baby  from  infection. 

5.  Definitely  protects  him  from  certain  nutritional  diseases. 

Cows'  milk,  suitably  modified,  is  apparently  the  best  available 
substitute  for  mother's  milk,  but  it  must  first  meet  certain  re- 
quirements and  then  be  handled  with  scrupulous  cleanliness  and 
care,  if  it  is  to  be  at  all  satisfactory. 

The  requirements  are  that  the  milk  shall  be : 

1.  Whole  milk.  It  must  not  be  altered  by  the  removal  of  cream 
nor  the  addition  of  such  preservatives  as  salicylic  acid,  formalde- 
hyde or  boracic  acid. 

2.  Its  composition  must  not  vary  greatly  from  day  to  day. 

3.  It  must  be  clean  and  free  from  disease  germs;  other  organisms 
should  not  be  present  in  excessive  numbers. 

4.  It  must  be  fresh :  less  than  24  hours  old  when  it  is  delivered. 

All  of  this  means  that  the  milk  must  come  from  a  herd  of 
healthy,  tuberculin-tested  cows.  The  milk  from  a  single  cow 
may  vary  markedly  from  day  to  day  but  that  from  several  cows 
is  nearly  constant.  The  stables  and  the  cows  must  be  kept  clean, 
the  udders  carefully  washed  before  each  milking;  the  milkers 
themselves  must  wear  freshly  washed  clothing,  scrub  their  hands 
thoroughly  and  milk  into  sterile  receptacles;  the  milk  must  be 
immediately  covered  and  cooled  to  a  temperature  of  45°  F.  or 
50°  F.  and  kept  there. 

Milk  produced  under  such  conditions  is  usually  described  as 
"certified  milk"  and  is  often  prescribed  as  infant  food  without 
being  pasteurized  or  sterilized.  But  if  there  is  any  doubt  about 
the  source  of  the  milk  and  the  method  of  its  handling,  it  should 
be  strained  into  a  clean  receptacle  through  filter  paper  or  a  thick 
layer  of  absorbent  cotton  and  subsequently  boiled  or  pasteurized. 

When  the  nurse  is  in  a  position  to  offer  advice  about  the 
baby 's  milk  she  must  explain  the  importance  of  always  obtaining 
the  freshest,  cleanest  and  purest  milk  possible,  no  matter  what 
it  costs. 

Whether  certified  or  not  the  milk  must  always  be  placed  in  the 
refrigerator  or  some  other  place  at  a  temperature  of  50°  F,  as 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY    491 

soon  as  it  is  received  and  it  mnst  he  kept  cool  and  clean. 
Mother's  milk,  which  is  being  imitated,  is  clean  and  sweet  and 
free  from  disease  germs. 

Keeping  the  milk  cool  means  keeping  it  at  a  temperature  of 
50°  F.  Keeping  it  clean  implies  cleanliness  of  the  milk  itself,  the 
utensils,  the  nurse's  hands  and  the  destruction,  by  sterilization 
or  pasteurization,  of  disease  germs.  Those  which  are  likely  to  be 
present  in  infected  milk  are  streptococci,  tubercle  bacilli,  colon 
bacilli,  germs  of  typhoid,  diphtheria  and  scarlet  fever. 

The  amounts  and  proportions  of  the  constituents  of  the  sub- 
stitute feeding  will  be  specified  by  the  doctor,  as  well  as  the  in- 
tervals between  feedings  and  the  amount  to  be  given  each  time. 
But  the  doctor's  careful  adjustment  of  the  milk  formula  to  the 
baby's  immediate  needs  and  digestive  powers  will  be  set  at 
naught  unless  the  nurse  is  absolutely  accurate  in  preparing  and 
giving  the  milk. 

The  nurse 's  invariable  responsibility,  therefore,  is  to  keep  the 
milk  cool  and  clean  and  prepare  and  give  it  accurately. 

The  nurse  will  appreciate  the  necessity  and  principles  of 
modifying  cows'  milk  for  the  human  infant  if  she  will  consider 
for  a  moment,  the  differences  between  mother's  milk  and  cows' 
milk,  as  indicated  by  the  following  table,  and  the  reasons  for 
these  differences: 

Mother's  Milk.  Cows'  Milk. 

Fats    3.5  to    4.  %  3.5  to    4.     % 

Sugar    6.5  to    7.5%  4.5  to    4.75% 

Proteins    1.     to     1.5%  3.5  to     4.     % 

Salts    .2%  .7  to       .75% 

Water    87      to  88.  %  87.     % 

It  will  be  remembered  that  the  tissues  and  bony  skeleton  are 
built  by  the  proteins  and  salts  (lime  and  phosphorus).  Ac- 
cordingly Nature  supplies  these  in  greater  abundance  to  the 
calf,  who  grows  so  fast  as  to  double  his  birth  weight  in  about 
47  days,  than  to  the  baby  who  scarcely  doubles  his  within  180 
days.  The  calf  begins  life  with  a  physical  need  for  the  abun- 
dance of  proteins  and  salts  which  are  present  in  cows'  milk,  and 
with  digestive  organs  that  can  cope  with  them,  but  the  baby 
needs  less,  can  digest  less  and  therefore  must  be   given  less. 


492  OBSTETRICAL  NURSING 

There  are,  of  course,  other  and  finer  differences  between  the  two 
milks  and  an  attempt  is  sometimes  made  to  meet  these.  For 
example,  mother's  milk  is  slightlj^  alkaline  and  cows'  milk 
slightly  acid  and  the  curd  of  cows'  milk  is  larger,  tougher  and 
harder  to  digest  than  that  formed  by  mother's  milk.  Accordingly 
some  doctors  add  lime  water  to  cows'  milk  to  make  it  alkaline, 
and  render  the  curd  softer,  finer  and  more  digestible  by  boiling  it. 

It  is  often  not  possible  to  give  a  bottle-fed  baby  the  full  4% 
of  fat  which  mother's  milk  contains,  and  some  doctors  make 
the  protein  of  the  artificial  mixture  very  much  larger  in  amount 
than  is  found  in  human  milk.  The  nurse  will  see  that  this  is  a 
matter  which  can  be  decided  only  by  the  physician. 

Articles  Needed  in  Preparing  the  Baby's  Food.  A  complete 
equipment  for  preparing  and  giving  the  baby's  milk  should  be 
assembled,  kept  in  a  clean  place,  separate  from  utensils  in  gen- 
eral use,  and  never  put  to  any  other  service.  A  satisfactory 
outfit  for  this  purpose  comprises  the  following  articles: 

One  dozen  graduated  niu'sing  bottles. 

One  dozen  nipples. 

Clean,  new  corks  or  a  package  of  sterile,  non-absorbent  cotton  for 
stoppers. 

Bottle  brush. 

Covered  kettle,  capacity  one  gallon,  for  boiling  bottles  and  possibly 
pasteurizing  milk. 

Pasteurizer  or  wire  bottle  rack. 

Small  kettle,  about  one  quart  size. 

Graduated  pint  or  quart  measuring  glass. 

Pitcher,  two  quart  size. 

Long-handled  spoon  for  mixing. 

Funnel. 

Measuring  spoons — table  and  tea  sizes. 

Double  boiler. 

Thermometer  which  will  register  at  least  212°  F, 

Cream  dipper  (if  ordered). 

Two  small  covered  jars  for  sterile  and  used  nipples. 

Sugar  (lactose,  maltose  or  cane  sugar  according  to  orders). 

Lime  water,  if  ordered. 

Utensils  of  enamel  or  aluminum  ware  are  probably  the  most 
satisfactory  ones  to  use  as  they  are  easily  kept  clean,  while  bot- 
tles with  wide  mouths  and  curved  bottoms  and  inner  surfaces 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     493 

can  be  thoroughly  washed  more  easily  than  those  with  small 
necks  and  sharp  corners.  Nipples  that  can  be  turned  inside  out 
to  be  washed  should  be  selected  as  it  is  almost  impossible  to  clean 
thoroughly  those  with  tubes  or  narrow  necks.  New  bottles  will 
be  rendered  less  breakable  if  placed  in  cold  water,  which  is 
gradually  heated,  allowed  to  boil  for  half  an  hour  and  cooled 
before  the  bottles  are  removed. 

The  bottles  should  be  rinsed  with  cold  water  after  each  feed- 


FiG.   168. — Preparing  the  baby's  milk.      (From  photograph  taken  at 
Johns  Hopkins  Hospital.) 

ing  and  then  carefully  washed  and  scrubbed  with  the  bottle 
brush  in  hot  soapsuds  or  borax  water,  containing  tAvo  table- 
spoonsful  to  the  pint.  They  may  be  kept  full  of  water  while 
not  in  use  or  rinsed  with  hot  water  and  stood  upside  down  until 
they  are  all  boiled  on  the  following  morning,  preparatory  to 
being  filled  with  the  freshly  prepared  milk.  The  baby 's  bottles 
should  never  be  washed  in  dishwater  nor  dried  on  a  towel.  The 
nipples  should  be  rinsed  in  cold  water,  turned  inside  out  and 


494  OBSTETRICAL  NURSING 

scrubbed  with  a  brush,  in  hot  soapsuds  or  borax  water;  rinsed 
and  placed  in  a  jar  ready  to  be  boiled  with  the  bottles. 

Preparation  of  Milk.  The  full  quantity  of  milk  which  the 
baby  will  take  in  the  course  of  twenty-four  hours  is  prepared 
at  one  time  and  the  prescribed  amount  for  each  feeding  poured 
into  as  many  separate  bottles  as  there  will  be  feedings.  (Fig. 
168.) 

The  nurse  should  first  boil  for  five  minutes  all  of  the  articles 
that  will  come  in  contact  with  the  milk,  including  the  full  num- 
ber of  bottles  and  nipples  and  the  jars  in  which  the  nipples  are 
kept;  remove  them  with  the  long-handled  spoon  without  touch- 
ing the  edges  or  inner  surfaces  and  place  them  on  a  clean  table, 
dropping  the  nipples  into  one  of  the  sterile  jars. 

She  should  wash  the  mouth  of  the  milk  bottle  before  remov- 
ing the  cap  and  pour  the  amount  which  the  formvda  calls  for 
into  the  sterile  pitcher.  To  this  is  added  the  sterile  water  in 
which  the  sugar  has  been  dissolved  in  the  glass  graduate,  and 
the  potato  or  barley  water,  the  lime  water  or  soda  solution  as 
ordered.  This  mixture  is  thoroughly  stirred  and  the  amount 
for  one  feeding  at  a  time  measured  in  the  graduate  and  poured 
into  the  specified  number  of  bottles  which  are  then  stoppered. 

If  certified  milk  is  used  for  the  milk  mixture  it  is  often  given 
to  the  baby  without  being  pasteurized,  in  which  case  the  bottles 
are  placed  in  the  refrigerator  as  soon  as  they  Lre  filled  and  stop- 
pered. Very  frequently,  however,  the  milk  is  sterilized  or 
pasteurized.  The  nurse  will  feel  surer  of  keeping  the  mouths 
of  the  bottles  clean  if  she  covers  them  with  squares  of  gauze  or 
muslin  before  they  are  sterilized,  holding  the  caps  in  place  with 
tapes  or  rubber  bands.  Pasteurization  as  applied  to  infant  feed- 
ing consists  of  heating  the  milk  to  140-165°  F.  and  keeping  it  at 
that  temperature  20  to  30  minutes. 

There  are  many  excellent  pasteurizers  for  home  use  on  the 
market,  or  entirely  satisfactory  results  may  be  obtained  by  using 
a  wire  bottle  rack  (See  Fig.  168)  and  the  large  kettle  already 
provided.  One  method  is  to  place  the  rack  containing  the  bottles 
in  the  kettle  which  is  filled  with  cold  water  to  a  level  a  little 
above  the  top  of  the  milk  in  the  bottles,  and  allow  the  water  to 
come  to  the  boiling  point.    The  kettle  is  removed  from  the  fire, 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     495 

covered  tightly  and  the  bottles  allowed  to  stand  in  the  hot  water 
for  twenty  miiiutos.  Cold  water  is  then  run  into  the  kettle  to 
cool  the  milk  gradually  and  avoid  breakinj^  the  bottles,  after 
which  they  are  placed  in  the  refrigerator,  well  or  spring-house 
and  kei)t  at  a  temperature  of  50°  F.  until  they  are  taken  out  one 
at  a  time  for  feedings.  If  a  wire  rack  is  not  available  the  bottles 
may  be  stood  on  a  saucer  or  a  thick  pad  of  folded  newspapers 
in  the  bottom  of  the  kettle. 

Pasteurization  does  not  destroy  all  germs  that  may  be  in 
the  milk,  but  it  kills  the  more  important  ones  and  apparently 
impairs  the  nutritive  and  protective  properties  of  the  milk  less 
than  boiling.  However,  pasteurized  milk  must  be  kept  cold  and 
must  be  used  within  twenty-four  hours,  for  the  nurse  will  recall 
that  aging  of  milk  is  quite  as  undesirable  as  souring. 

Scalding  is  another  method  of  destroying  germs  in  milk. 
The  milk  is  placed  in  an  open  vessel  and  the  temperature  raised 
to  about  180°  F.,  or  until  bubbles  appear  around  the  edge  and 
the  milk  steams  in  the  centre,  after  which  it  is  cooled  and  kept 
at  a  temperature  of  50*^  F. 

Many  doctors  prefer  to  have  the  baby's  milk  boiled,  since 
boiling  insures  absolute  sterilization  and  also  renders  the  curd 
more  digestible.  Other  changes  are  produced  by  boiling,  how- 
ever, which  make  it  important  to  add  an  anti-scorbutic  and  cod- 
liver  oil  to  the  baby's  diet  at  an  early  date. 

Milk  may  be  boiled  directly  over  the  flame  for  a  time  varying 
from  three  to  forty-five  minutes,  or  it  may  be  placed  in  a  double 
boiler,  the  water  in  the  lower  receptacle  being  cold,  and  allowed 
to  remain  until  the  water  has  boiled  from  six  to  forty-five  min- 
utes.   All  of  these  points  are  definitely  specified  by  the  doctor. 

When  milk  is  boiled  or  scalded  the  other  ingredients  are 
added  beforehand,  as  a  rule,  after  which  it  is  measured  and 
poured  into  the  bottles.  Or  the  milk  mixture  may  be  poured 
into  the  bottles  as  for  pasteurization  and  the  bottles  kept  in  the 
actively  boiling  water  for  any  desired  length  of  time. 

Giving  the  Baby  His  Bottle.  At  feeding  time,  th»  bottle 
should  be  taken  from  the  refrigerator,  the  stopper  removed  and 
a  nipple  taken  up  by  the  margin  and  put  on  the  bottle  without 
touching  the  mouthpiece.    The  milk  is  brought  to  a  temperature 


496 


OBSTETRICAL  NURSING 


of  about  100°  F.  by  standing  the  bottle  in  a  deep  cup  or  kettle 
of  warm  water  and  placing  it  on  the  fire.  The  temperature  of 
the  milk  may  be  tested  by  dropping  a  few  drops  on  the  inner  side 
of  the  wrist  or  forearm  where  it  should  feel  warm  but  not  hot. 


Fig.  169. — Proper  position  in  which  to  hold  baby  and  bottle  during  feeding. 

This  dropping  will  also  indicate  if  the  hole  in  the  nipple  is  of 
the  proper  size  to  allow  the  milk  to  drop  rapidly  in  clean  drops 
but  not  to  pour.  If  the  hole  is  too  small,  the  drops  will  be  small 
and  infrequent  and  the  baby  will  be  obliged  to  work  too  hard 
to  obtain  it ;  while  if  the  hole  is  too  large  the  baby  will  feed  to 
rapidly  and  may  have  colic  as  a  result. 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     497 

The  baby's  diaper  should  be  changed  if  it  is  soiled  or  wet  be- 
fore he  is  given  the  bottle  and  he  should  be  held  comfortably 
in  a  reclining  position  on  the  nurse's  arm  while  she  holds  the 
bottle  with  her  free  hand.     (Fig.  169.)     The  bottle  should  be 


Fig.  170. — Holding  the  baby  iipriylit  ami  gently   patting  his  back  to 
bring  up  air  immediately  after  feeding. 

inclined  sufficiently  to  keep  the  neck  full  of  milk ;  otherwise 
the  baby  may  draw  in  air  as  he  nurses.  He  should  be  kept  awake 
while  feeding  but  he  should  be  allowed  to  pause  every  three  or 
four  minutes  in  order  not  to  take  his  milk  too  rapidly.  Not 
less  than  ten  nor  more  than  twenty  minutes  is  devoted  to  a  feed- 
ing, as  a  rule,  and  if  the  baby  refuses  a  part  of  his  milk,  it  should 
be  thrown  away ;  never  warmed  over  for  another  time. 

After  being  fed,  the  baby  should  be  held  upright  against 
the  nurse's  shoulder  for  a  moment  or  two  (Fig.  170),  and  ever 


498  OBSTETRICAL  NURSING 

so  gently  patted  on  the  back  to  help  bring  up  any  air  which  he 
may  have  swallowed.  He  should  on  no  account  be  rocked  or 
played  with  after  taking  the  bottle,  but  should  be  placed  gently 
in  his  crib,  warm  and  dry  and  left  alone  to  sleep.  Turning  him 
or  moving  him  about  even  to  the  extent  of  changing  his  diaper 
at  this  time  may  cause  vomiting. 

The  evidences  of  satisfactory  and  unsatisfactory  feeding  in 
the  bottle-fed  baby  are  about  the  same  as  in  the  baby  who  is 
fed  at  the  breast,  except  that  the  gain  in  weight  on  artificial 
food  may  be  a  little  slower  and  less  steady  than  on  maternal 
nursing;  the  stools  have  a  characteristic  sour  odor;  are  a  little 
lighter  in  color  and  may  contain  white  lumps  of  undigested 
fat ;  are  usually  dryer  than  in  breast-feeding  and  may  be  formed 
in  even  a  very  young  baby. 

It  is  fairly  generally  agreed  that  all  babies,  whether  breast- 
fed or  on  the  bottle,  require  a  certain  amount  of  cool  boiled 
water  to  drink  between  feedings.  A  small  amount  is  given  at 
first  and  gradually  increased  according  to  the  doctor's  instruc- 
tions, and  it  may  be  given  from  a  bottle,  a  medicine  dropper  or 
poured  slowly  from  the  tip  of  a  teaspoon. 

Ingredients  of  the  Baby's  Food.  In  referring  to  the  ingre- 
dients of  the  baby's  food  we  cannot  use  the  terms  "sugar"  or 
"milk"  as  though  they  indicated  definite  and  unvarying  mate- 
rials. 

There  are  three  kinds  of  sugar  which  are  commonly  used 
in  modified  milk:  cane  or  granulated  sugar;  lactose  or  milk 
sugar  and  maltose.  Cane  sugar,  the  one  most  widely  used,  is 
the  least  expensive  of  the  three  and  it  apparently  is  satisfactory 
for  most  babies.  Lactose  is  fairly  expensive  and  while  it  causes 
diarrhea  in  some  babies,  others  digest  it  more  easily  than  cane 
sugar.  Lactose  is  lighter  than  cane  sugar,  three  spoonfuls  being 
equal  in  weight  to  two  of  cane  sugar.  The  maltose-dextrme 
preparations  are  easily  digested  and  somewhat  laxative.  Some 
babies  gain  more  rapidly  when  maltose  constitutes  part  of  the 
sugar  in  their  food  than  when  only  lactose  is  used. 

The  question  of  milk  is  somewhat  complicated  and  though 
the  doctor  will  specify  what  percentage  of  fat  shall  be  in  the 
milk  which  is  used  in  each  case,  the  nurse  must  know  how  to 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     499 

obtain  it  from  the  milk  at  ner  disposal.  If  the  formula  is  made 
up  with  "whole  milk,"  which  contains  4  per  cent,  fat,  the  bottle 
in  W'hich  it  was  delivered  should  be  turned  upside  down  and 
shaken  vigorously  in  order  that  the  cream  which  has  risen  to 
the  top  may  be  redistributed  evenly  throughout  the  fluid. 

If  the  doctor  employs  what  is  termed  "percentage  feeding," 
he  may  use  whole  milk,  skimmed  milk,  or  top  milk.  What  he 
is  endeavoring  to  do  is  to  prepare  a  food  which  contains  definite 
known  percentages  of  the  different  ingredients,  fat,  carbohy- 
drates and  protein.  Where  a  mixture  is  desired  which  contains 
more  fat  than  it  docs  protein,  the  milk  to  be  employed  is  ob- 
tained by  discarding  a  certain  amount  from  the  bottom  of  the 
jar  of  milk,  the  remainder  being  then  called  "top  milk."  When 
he  wishes  the  fat  to  be  lower  than  the  protein  percentage,  he 
discards  some  of  the  top  milk  in  the  jar,  using  the  rest,  which 
is  then  a  partially  skimmed  milk.  The  upper  2  ounces  in  a 
quart  bottle  of  milk  contains  24  per  cent,  fat ;  the  upper  8  ounces 
is  12  per  cent,  fat;  the  upper  16  ounces  is  8  per  cent,  fat  and 
the  upper  24  ounces  is  5  per  cent.  fat.  If  the  formula  calls  for 
6  ounces  of  the  upper  8  ounces  of  milk,  therefore,  the  nurse  will 
see  that  it  is  very  important  that  she  remove  the  full  8  ounces 
and  use  6  ounces  of  the  milk  which  she  has  removed  and  not 
simply  take  the  upper  6  ounces,  as  this  would  contain  a  higher 
percentage  of  fat  than  is  ordered.  (Figs.  171,  172,  Dr.  Griffith's 
tables  of  fat  percentages.) 

Top  milk  may  be  removed  by  tipping  the  bottle  gradually 
and  slowly  pouring  the  designated  amount  into  a  measuring 
glass,  or  it  may  be  removed  by  pushing  a  cream  dipper,  especially 
made  for  this  purpose  and  holding  one  ounce,  down  into  the 
bottle  until  the  cream  flows  in.  Another  method  is  to  syphon 
off  the  lower  milk  through  a  bent  glass  tube,  leaving  in  the  bottle 
the  desired  amount  of  top  milk. 

Many  doctors  feed  the  baby  according  to  his  caloric  needs 
and  prepare  the  formula  from  whole  milk,  sugar  and  water, 
determining  the  amounts  of  each  according  to  the  age  and  weight 
of  the  baby. 

Under  any  condition  it  is  so  necessary  that  the  amount  and 
composition  of  each  baby's  food  be  adjusted  to  his  needs,  that 


500 


OBSTETRICAL  NURSING 


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NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     501 

it  is  not  considered  possible  to  make  out  any  formulae  or  feeding 
schedules  Avhich  would  be  safe  or  satisfactory  for  general  use. 
Moreover,  it  does  not  ordinarily  devolve  upon  the  nurse  to 
do  more  than  prepare  and  give  the  baby's  food  as  ordered  by 
the  doctor,  but  situations  sometimes  do  arise  when  the  doctor 


Table   Giving  Approximate   Percrntage- 
Stuengtiis  or  Different  Layers  of  Milk 


ci 

<U  CIS 

0;  t-   c 

.2 

.  .24 

4 

4 

6  tol 

4  •'  . 

.  .20 

.5  tol 

6  "  . 

..16 

4 

4  tol 

8  "  . 

..12 

4 

3  tol 

"      10". 

.10 

4 

2..')  tol 

"      16  "  . 

..   8 

4 

2  tol 

"      20  "  . 

.    6 

4 

1.5  to  1 

"      24  "  . 

4 
4 

1.25  to  1 

1       "»    32  " 

whole 
milk 

\      * 

1  to  1 

■jower  30  "  . 

.    3 

4 

.75  to  1 

"      28  "  . 

9 

4 
4 

.50  to  1 

"      16". 

.     1 

.25  to  1 

"        8". 

.  o.s 

4 

.Otol 

To  Find  the  Amount  of  Any  Layer  op  Milk 
TO  liE  Used  to  Give  Percentages  Desired 

Kiiuation : 

Total   amount   of    food  X  Per- 
centaRe  of  fat  desired 


Amount        of 
r=  tills    milk    in 
Fat-strength  of  layer  of  milk  u.sed      (j,g   mixture. 

(1)  Select  from  the  "Layers  of  Milk"  Table  the 
milk  which  possesses  the  desired  ratio  of 
fat  to  protein. 

(2)  Substitute  in  the  equation. 

(3)  As  the  sugar-percentage  has  been  reduced 
equally  with  that  of  the  protein,  add  suffi- 
cient sugar  to  raise  to  the  desired  per- 
centage. 

Example:  20-oz.  mixture  desired.  Percentages 
desired  =  Fat  3,  Sugar  6.  Protein  1.  Use 
upper   8   oz.    (fat   12%,   protein   4%,   viz.: 

20  X  3 
3:1).     Then "    ^ .., —  =  5  oz.  of  upper  8  oz., 

with  15  oz.  of  water  in  the  20-oz.  mixture. 
The  protein  necessarily  becomes  1%,  and 
the  sugar  likewise.  The  mixture  already 
containing  1%  of  sugar,  add  5%  of  20  oz., 
i.  e.,  1  oz.  of  sugar  to  increase  this  to  the 
C%  desired. 


To  Determine  the  Percentages  Present  in  Any  Milk-Mixture  Already  in  Use 

Quantity  of  substsance  used   (milk,  cream,  or  skimmed  milk) 

X  Its  percentage-strength  _  Percentage    of    element  (F., 

T^t^Quantity  of  Food  «•  or  P.)   in  the  mixture. 

Example:    The  mother  has  mixed:    Upper  8  oz.  ;  6  oz. — Lower  8  oz.  ;  3  oz. — -Milk-sugar  3 

level  tablespoonfuls. — Water  27  oz.     Total  quantity  =  36  oz.     The  upper  8  oz.  contains 

12%    fat    (see  Table).      Both   top    and    bottom   milk    contain    4%    protein    and    sugar. 

Three  tablespoonfuls  sugar  ^  approximately   1   oz.     The  fat  of  the  lower  8  oz.  may  be 

ignored.      Then — ;^ — "=■  2  =Fat   percentage   from    the   top-milk. 


36 

percentage  from  the  bottom  milk. 


36 


■  =  0  =  Fat- 


9X4 
36 


1  =Protein  and  sugar  percentages  from 

combined  top  and  bottom  milk.  The  1  oz.  additional  sugar  divided  by  30  =  approx- 
imately 3%  sugar  added.  There  being  already  1%  sugar  derived  from  the  milk,  the 
total  sugar  =  4%. 

Fio.  172.     Reverse  side  of  card  in  Fi<r.  171. 


is  not  within  reach  which  the  nurse  must  meet  as  best  she  can. 
In  such  an  emergency  she  might  be  guided  by  the  following 
suggestions  contained  in  a  pamphlet  entitled,  '  *  Save  the  Babies, ' ' 
prepared  by  Dr.  L.  Emmet  Holt  and  Dr.  II.  K.  L.  Shaw  and 
published  by  the  American  Medical  Association,  remembering 
that  they  are  intended  for  the  average,  normal  baby  and  are 
not  necessarily  suitable  for  all  babies: 


502  OBSTETRICAL  NURSING 

''The  simplest  plan  is  to  use  whole  milk  (from  a  shaken  bottle) 
which  is  to  be  diluted  according  to  the  child's  age  and  digestion. 

"Beginning  on  the  third  day,  the  average  baby  should  be  given  3 
ounces  of  milk  dail}',  diluted  with  seven  ounces  of  water.  To  this 
should  be  added  one  tables^Doonful  of  lime  water  and  2  level  teaspoon- 
fuls  of  sugar.     This  should  be  given  in  seven  feedings. 

"At  one  week,  the  average  child  requires  5  ounces  of  milk  daily, 
which  should  be  diluted  with  10  ounces  of  water.  To  this  should  be 
added  1^2  even  tablespoonfuls  of  sugar  and  one  ounce  of  lime  water. 
This  should  be  given  in  seven  feedings. 

"The  milk  should  be  increased  by  1/2  ounce  about  every  4  days. 

"The  water  should  be  increased  by  I/2  ounce  about  every  8  days. 

"At  three  months  the  average  child  requires  16  ounces  of  milk  daily, 
which  should  be  diluted  with  16  ounces  of  water.  To  this  should  be 
added  3  tablespoonfuls  of  sugar  and  2  ounces  of  lime  water.  This 
should  be  given  in  6  feedings. 

"The  milk  should  be  increased  by  ^  ounce  about  every  6  days, 

"The  water  should  be  reduced  by  %  ounce  about  every  2  weeks. 

"At  6  months  the  average  child  requires  24  ounces  of  milk  daily, 
which  should  be  diluted  with  12  ounces  of  water.  To  this  should  be 
added  2  ounces  of  lime  water  and  3  even  tablespoonfuls  of  sugar.  This 
should  be  given  in  5  feedings. 

"The  amount  of  milk  should  be  increased  by  Yz  ounce  every  week. 

"The  milk  should  be  increased  only  if  the  child  is  hungry  and  di- 
gesting his  food  well.  It  should  not  be  increased  unless  he  is  hungry, 
nor  if  he  is  suffering  from  indigestion  even  though  he  seems  hungrj'. 

"At  9  months,  the  average  child  requires  30  ounces  of  milk  daily, 
which  shoiild  be  diluted  with  10  ounces  of  water.  To  this  should  be 
added  2  even  tablespoonfuls  of  sugar  and  2  ounces  of  lime  water. 
This  should  be  given  in  5  feedings. 

"The  sugar  added  may  be  milk  sugar  or,  if  this  cannot  be  obtained, 
cane  (granulated)  sugar  or  maltose  (malt  sugar). 

"At  first  plain  water  should  be  used  to  dilute  the  milk. 

"At  three  months,  sometimes  earlier,  weak  barley  water  may  be 
used  in  the  place  of  plain  water;  it  is  made  with  1/2  level  tablespoonful 
of  barley  flour  to  16  ounces  of  water  and  cooked  20  minutes. 

"At  six  months  the  barley  flour  may  be  increased  to  IV2  even  table- 
spoonfuls, cooked  in  the  12  ounces  of  water. 

"At  nine  months,  the  barley  flour  may  be  increased  to  3  level  table- 
spoonfuls, cooked  in  the  8  ounces  of  water. 

"A  very  large  baby  may  require  a  little  more  milk  than  that  allowed 
in  these  formulas.  A  small  delicate  baby  will  require  less  than  the 
milk  allowed  in  the  formulas." 

These  formulas  may  be  tabulated  as  follows : 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     503 


Age 


Water 


Harley- 
Water 


Lime- 
Water 


Sugar 


No.  o) 
feed- 
ings 


Hours 


Day 


Night 


3d 

1  ir 

2 

3 

4 

5 

6 

7 

8 

9 


days 

3      ozs. 

7      ozs. 

Vi  ozs.  1 

veek 

5        " 

10       " 

" 

6 

10^6   " 

onth 

7       " 

11 

11 

13 

IVz    ' 

10 

16  ozs. 

19 

15   " 

21  Vz    " 

14   " 

24 

12    " 

20 

12   " 

2  s        " 

n  " 

■Aii 

10    " 

2  teaspoons 

1  Vi  tablespoons 
11^ 

2  " 
2V^ 

3 
3 
3 
3 
3 


7 

0-9-12-3-6 

7 

0-9-12-3-6 

7 

0-9-12-3-6 

7 

6-9-12-3-6 

7 

6-9-12-3-0 

7 

6-9-12-3-6 

0 

6-9-12-3-6 

6 

6-9-12-3-6 

5 

0-10-2-6 

5 

0-10-2-6 

5 

6-10-2-6 

5 

0- 10-2-6 

10-2 
10-2 
10-2 
10-2 
10-2 
10-2 


Mixed  Feeding.  Under  some  conditions  the  breast-fed  baby 
is  given  also  a  certain  amount  of  modified  milk,  and  this  com- 
bination of  natural  and  artificial  feeding  is  termed  mixed  or 
supplementary  feeding. 

A  deficiency  in  the  breast  milk,  ascertained  by  weighing  the 
baby  before  and  after  each  nursing,  may  be  supplied  by  follow- 
ing each  nursing  with  a  bottle  feeding;  or  one  or  two  breast- 
feedings,  in  the  course  of  the  day  may  be  replaced  by  entire 
bottle  feedings.  In  any  case  the  milk  mixture  to  be  used  as  sup- 
plementary feeding  is  prepared  with  exactly  the  same  pains- 
taking care  as  is  the  milk  for  entire  artificial  feeding. 

If  supplementary  food  is  given  because  of  an  inadequate 
supply  of  breast  milk,  it  is  of  great  importance  that  the  baby 
be  put  to  the  breast  regularly,  no  matter  how  little  food  he  ob- 
tains, for  his  suckling  is  the  best  possible  means  of  stimulating 
the  breasts  to  secrete  more  milk  and  of  equal  importance  is  the 
fact  that  they  will  tend  to  dry  up  if  the  baby  nurses  less  than 
about  five  times  in  twenty-four  hours.  Moreover,  even  a  little 
breast  milk  is  valuable  to  him  and  he  should  have  the  benefit  of 
all  there  is  to  be  had. 

An  entire  bottle  feeding  is  sometimes  given  to  a  baby  who  is 
nursing  satisfactorily  at  the  breast,  in  order  to  give  his  mother 
an  opportunity  to  take  longer  outings  than  are  possible  between 
the  regular  nursings.  And  sometimes  it  is  to  the  mother's  ad- 
vantage, and  therefore  to  the  baby 's,  to  give  him  a  bottle  during 
the  night  and  thus  allow  her  to  sleep  undisturbed. 

COMMERCIAL  BABY  FOODS 

Since  the  baby's  food  is  prescribed  by  the  doctor,  the  nurse 
has  little  concern  with  the  various  proprietary  baby  foods  and 


504  OBSTETRICAL  NURSING 

the  canned  and  powdered  milks  which  are  so  persuasively  adver- 
tised to  young-  mothers.  It  is  hoped,  however,  that  the  discus- 
sions on  nutrition  in  general  and  on  baby  feeding  in  particular, 
have  made  it  clear  to  the  nurse  that  these  foods  cannot  be  ex- 
pected to  be  satisfactory  if  used  as  a  sole  article  of  diet  through- 
out the  bottle-feeding  period. 

There  are  many  times  and  circumstances,  however,  when  the 
temporary  use  of  a  prepared  infant  food  or  canned  or  powdered 
milk  is  advantageous.  In  some  cases  of  intestinal  disturbance, 
for  instance,  or  while  the  mother  is  traveling  and  is  unable 
to  have  freshly  prepared  milk  formulas  supplied  to  her  along  the 
way;  during  the  summer,  while  staying  at  a  hotel  or  boarding 
house  where  the  freshness,  cleanliness  or  purity  of  the  milk  are 
uncertain;  or  during  a  sudden  shortage  of  fresh  milk,  as  may 
occur  during  a  strike  or  severe  storm  when  transportation  is 
interfered  with,  a  proprietary  food  may  be  a  great  boon. 

If  the  nurse  is  confronted  with  the  necessity  of  choosing 
and  making  temporary  use  of  a  prepared  food  she  may  be  guided 
by  considering  the  general  principles  of  baby  feeding  and  the 
character  of  the  materials  at  her  disposal. 

The  Proprietary  Foods  may  be  divided  into  two  general 
groups:  one  kind  contains  milk  powder  and  is  usually  added 
to  water  while  the  other  consists  largely  of  sugar  and  starch 
and  is  added  to  fresh  milk  before  being  given  to  the  baby. 

Canned  Milk  is  of  two  kinds ;  evaporated,  which  is  unsweet- 
ened, and  condensed,  which  is  sweetened.  Evaporated  milk 
is  whole  milk  from  which  part  of  the  water  has  been  removed, 
the  milk  then  being  canned  and  sterilized.  The  addition  of 
water  to  evaporated  milk  restores  it  to  the  composition  of  whole 
milk  in  many  respects,  but  it  is  still  milk  that  has  been  heated. 
Condensed  milk  is  evaporated  milk  to  which  cane  sugar  has 
been  added  to  aid  in  its  preservation.  Since  bacteria  do  not 
grow  well  in  highly  sweetened  foods,  it  is  not  necessary  to  bring 
sweetened  condensed  milk  to  as  high  a  temperature  as  the  un- 
sweetened product,  to  prevent  subsequent  bacterial  decomposi- 
tion. The  high  percentage  of  sugar  in  condensed  milk  quite 
obviously  renders  it  unsuitable  for  continuous  use  as  the  sole 
article  in  a  baby's  dietary. 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     505 

Milk  Powders  or  Dried  Milks  are  prepared  by  rapidly 
evaporating  the  water  from  whole  milk,  skimmed  milk  or  partly 
skimmed  milk,  leaving  the  solid  constituents  in  the  form  of  a 
light,  white  powder.  Milk  powder  readily  dissolves  in  water, 
forming  a  "reconstructed  milk"  which  closely  resembles  the 
fresh  milk  from  which  it  was  prepared.  But  it  must  not  be 
forgotten  that  reconstructed  milk  has  been  heated.  Many  doc- 
tors consider  whole  milk  powder  the  most  satisfactory  form  of 
preserved  milk  which  is  available  for  baby  food.  Should  it  be 
used,  however,  the  importance  of  Keeping  it  tightly  covered  and 
in  a  cold  place  must  be  recognized,  for  the  presence  of  fat  renders 
it  likely  to  become  rancid  if  not  kept  cold. 

ARTICLES  OF  FOOD  WHICH  ARE  SOMETIMES 
INCLUDED  IN  THE  BABY'S  DIETARY 

Barley  Water,  sometimes  used  to  dilute  whole  milk,  is  made 
by  mixing  the  barley  flour  to  a  smooth  paste  in  cold  water,  add- 
ing boiling  water  and  boiling  for  twenty  minutes  or  cooking 
in  a  double  boiler  for  an  hour,  straining  and  adding  enough 
water  to  replace  the  amount  lost  in  cooking.  The  proportions 
for  different  ages  are  as  follows: 

Three  months,  V2  level  tablespoonful  barley  flour  to  16  oz.  water 
Six  months,  iy2  level  tablespoonful  barley  flour  to  12  oz.  water. 
Nine  months,  3  level  tablespoonfuls  barley  flour  to  10  oz.  water. 

Potato  Water.  One  tablespoonful  of  thoroughly  boiled 
potato  is  mashed  into  one  pint  of  the  water  in  which  the  potato 
was  boiled  and  carefully  strained. 

Spinach.  Spinach  is  carefully  washed,  steamed  for  half  an 
hour  and  mashed  through  a  fine  sieve.  It  is  sometimes  started 
at  the  sixth  month;  one  teaspoonful  daily,  gradually  increased 
to  one  or  two  tablespoonfuls  daily. 

Orange  Juice.  The  orange  should  be  dipped  in  boiling  water 
and  wiped  on  a  clean  towel  before  being  cut  and  squeezed,  to 
avoid  possible  infection  of  juice.  It  is  usually  given  to  babies 
getting  heated  milk,  sometimes  as  young  as  one  month  old.  It 
is  carefully  strained  and  started  gradually  by  giving  one  tea- 
spoonful  in  water  once  or  twice  daily  between  feedings  and 


506  OBSTETRICAL  NURSING 

increasing  to  y^  or  1  ounce  by  the  sixth  month  and  IV2  to  2 
ounces  by  the  end  of  the  first  year. 

Infusion  of  Orange  Peel.  This  is  sometimes  used  instead  of 
orange  juice,  and  is  made  by  boiling  one  ounce  of  finely  grated 
orange  peel  in  two  ounces  of  water,  adding  a  little  sugar  to 
counteract  the  bitter  taste  and  adding  enough  sterile  water  to 
bring  it  up  to  two  ounces. 

Tomato  Juice.  Canned  tomato  strained  through  a  fine  sieve, 
is  sometimes  given  to  a  baby  a  few  weeks  old,  starting  with  one 
dram  and  gradually  increasing  to  four  to  six  ounces  daily. 

Whey.  One  quart  of  whole  milk  heated  to  98°  F.  or 
100°  F.  and  one-half  ounce  of  liquid  rennet  or  one  junket  tablet 
stirred  into  it  and  allowed  to  stand  half  an  hour  or  until  firm 
and  solid,  is  poured  into  a  cheese-cloth  bag  and  allowed  to  drain 
for  about  an  hour  without  being  squeezed. 

Protein  Milk.  The  curd  from  one  quart  of  milk,  which  re- 
mains after  the  whey  is  drained,  as  directed  above,  is  mashed 
through  cheese-cloth  in  a  fine  wire  sieve,  with  a  potato-masher 
or  bowl  of  a  spoon  and  the  curd  washed  through  with  one  pint 
of  water.  A  pint  of  buttermilk  is  added  and  the  mixture  boiled 
while  being  stirred  constantly.  This  is  sometimes  given  in 
diarrhea. 

Beef  Juice.  One  pound  of  thick  round  steak,  slightly  broiled, 
is  cut  into  small  pieces  and  the  juice  expressed  with  a  meat 
press  or  a  lemon  squeezer,  the  amount  varying  from  2  to  3  ounces. 
It  may  be  diluted  with  an  equal  amount  of  warm  water,  or 
slightly  warmed  by  being  placed  in  a  cup  standing  in  hot  water, 
and  salted  to  taste. 

Broths.  One  pound  of  lean  meat,  all  fat  and  gristle  re- 
moved, is  allowed  to  one  pint  of  water.  The  meat  is  cut  finely 
and  put  on  in  cold  water,  heated  slowly  and  allowed  to  simmer 
for  three  or  four  hours,  when  water  is  added  to  replace  what 
was  lost  in  cooking.  It  is  strained,  the  fat  removed  and  slightly 
salted/ 

Oatmeal  Water.  Two  level  tablespoonfuls  of  oatmeal  in  a 
pint  of  boiling  water  is  cooked  in  a  double-boiler  for  two  hours, 
strained  and  enough  boiling  water  added  to  replace  the  amount 
lost  in  cooking. 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     507 


TRAVELING 

The  difficulties  of  traveling  with  a  young  baby  may  be 
greatly  lessened  by  making  certain  preparations.  If  the  baby 
is  bottle-fed,  the  preparations  will  depend  upon  the  length 
of  the  journey  and  whether  or 
not  it  will  be  possible  to  have 
freshly  prepared  feedings,  for 
each  twenty-four  hours,  put 
on  the  train  from  laboratories 
along  the  way.  If  this  is  not 
possible  and  the  journey  is 
not  to  take  more  than  twenty- 
four  hours,  the  entire  quan- 
tity of  food,  ice  cold,  may  be 
carried  in  a  thermos  bottle. 
The  requisite  number  of  ster- 
ile nursing  bottles  may  be 
taken  or  one  bottle  which  is 
boiled  before  each  feeding.  Or 
the  milk  may  be  prepared  as 
usual  and  the  bottles  packed 
in  a  portable  refrigerator. 
Such  a  refrigerator  may  be  bought  or  one  may  be  improvised. 
The  bottles  are  placed  in  a  covered  pail  and  packed  solidly  in 
(yushed  ice ;  this  is  placed  in  a  second  pail  or  a  box  with  a  diam- 
eter which  is  at  least  two  inches  larger  than  the  inner  pail  and 
the  space  between  the  two  packed  firmly  with  sawdust.  Several 
thicknesses  of  newspapers  should  be  pressed  down  over  the  top 
and  a  tight  cover  fitted  to  the  outer  receptacle. 

The  sterile  nipples  may  be  taken  in  a  sterile  jar  and  a  deep 
cup  or  kettle  w'ill  be  needed  in  which  to  warm  the  bottle  before 
each  feeding.  It  is  usually  possible  to  obtain  water  on  the  train 
which  is  hot  enough  for  this,  or  cans  of  solid  alcohol,  a  stand 
and  a  metal  tray  may  be  added  to  the  traveling  outfit.  If  fresh 
formulae  cannot  be  delivered  to  the  train,  dail}',  and  the  journey 
is  to  last  more  than  twenty-four  hours,  one  of  the  proprietary 
foods  or  a  powdered  milk  will  often  prove  to  be  a  satisfactory 
solution  to  the  problem  of  feeding. 


Fig.  173. — The  baby  will  travel 
comfortably  in  a  basket  converted 
into  a  bed.  (Courtesy  of  the  Ma- 
ternity Centre  Association.) 


508  OBSTETRICAL  NURSING 

The  baby  will  usually  travel  more  comfortably  and  sleep 
better  if  he  is  carried  in  a  basket.  A  large  market  basket  with 
a  handle  or  a  small  clothes  basket  will  serve.  It  may  be  lined 
with  a  sheet  or  a  blanket;  have  a  small  hair  pillow  or  folded 
blanket  in  the  bottom  and  be  made  up  like  a  crib.  (Fig.  173.) 
If  this  basket  stands  on  the  ear  seat  during  the  day,  and  on  the 
foot  of  the  nurse's  berth  at  night,  the  baby  will  be  cleaner, 
quieter  and  less  exposed  to  drafts  than  if  carried  in  the  arms. 


THE  PREMATURE  BABY 

All  of  the  precautions  and  gentleness  which  are  necessary  iu 
the  care  of  the  normal  baby,  born  at  term,  must  be  greatly  in- 
creased in  caring  for  the  baby  who  is  born  prematurely. 

As  was  explained  in  Chapter  III  the  premature  baby's  pros- 
pects of  living  increase  with  the  length  of  his  uterine  life,  and 
it  is  often  j)ossible  to  estimate  this  by  measuring  and  weighing 
him.  During  the  last  five  months  the  child's  length  in  centi- 
metres divided  by  five  gives  the  month  of  pregnancy,  according 
to  the  following  table  by  Dr.  Williams :  ^ 

At  the  fifth  month  of  pregiiancy 5x5,  fetus  is  25  cm.  long 

At  the  sixth  mouth  of  preiiuauey 6x5,  fetus  is  30  cm.  long' 

At  the  seventh  month  of  pregnancy 7x5,  fetus  is  35  cm.  long 

At  the  eighth  month  of  pregnancy 8x5,  fetus  is  40  cm.  long 

At  the  ninth  month  of  pregiiancy 9x5,  fetus  is  45  cm.  long 

At  the  tenth  month  of  pregnancy 10x5,  fetus  is  50  cm.  long 

But  consideration  of  the  baby's  weight  is  also  of  importance 
when  attempting  to  forecast  his  chances  of  living.  A  baby 
weighing  less  than  2500  grams  or  about  5i/2  pounds  should  be 
regarded,  and  treated,  as  premature,  unless  it  is  more  than  45 
centimetres,  or  about  18  inches  long.  This  length  would  indicate 
greater  maturity,  and  therefore  greater  viability  than  would  be 
expected  from  the  weiglit.  A  baby  weighing  less  than  1500 
grams  (3  pounds  and  5  ounces)  can  scarcely  be  expected  to  live. 

The  premature  baby  is  not  only  small,  but  in  general  is  im- 
perfectly developed,  having  slenderer  powers  than  the  full-term 

^"Obstetrics,"  by  J.  Whitridge  Williams. 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     509 

baby  and  at  tbe  same  time  much  greater  needs.  His  respiratory 
and  digestive  organs  are  less  ready  to  function  than  in  the  full- 
term  baby ;  his  muscles  and  nerves  are  feeble ;  his  heat-producing 
mechanism  is  unstable  and  yet  there  is  an  excessive  radiation  of 
body  heat  through  the  relatively  large  area  of  skin. 

Accordingly,  the  baby  who  has  been  deprived  of  those  valu- 
able last  weeks  of  growth  and  development  is  small  and  limp; 
lies  quietly  most  of  the  time  and  moves  very  feebly  if  at  all. 
He  is  often  too  weak  to  nurse  at  the  breast  and  may  swallow 


TiQ.  174. — Quilted  robe,  with  hood,  for  the  premature  baby. 

with  difficulty.    His  temperature  is  low,  his  respirations  irregu- 
lar and  he  is  frequently  cyanotic. 

The  care  of  this  frail  little  body  practically  resolves  itself 
into : 

1.  Maintaining  a  normal  body  temperature. 

2.  Proniotinjj  and  niaintaininsr  nonnal  respirations. 

3.  Supplying-  adeqiiate  and   suitable  nourishment. 

4.  Conserving  his  strength. 
6.  Preventing  infection. 


510 


OBSTETRICAL  NURSING 


aik^tSg&m 


Fig.  175. — Premature  baby  in  basket  lined  with  quilted  pad;  wearing 
quilted  robe  and  being  fed  from  a  Boston  feeder.  The  blanket  is  turned 
back  showing  hot-water  bag.  (From  photograph  taken  at  Johns  Hopkins 
Hospital.) 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     511 

To  maintain  a  normal  body  temperature  it  is  necessary  to  give 
special  thought  to  the  lialty's  chithiii'i,-,  bed  and  room.  lie  sliould 
be  oiled  with  Avarm  olive  oil  and  entirely  wrapped  in  cotton 
batting  or  flannel  or  enveloped  in  a  quilted  garment,  with  hood 


Fig.  176. — Model  of  improvised  bed  for  premature  baby:  closely  woven 
clothes  basket  with  padded  bottom  ami  four,  flannel-covered  bottles  of  hot 
water  attached  to  the  sides.  Thermometer  and  feeder  are  shown  in  basket. 
(By  courtesy  of  Dr.  Alan  Brown,  Hospital  for  Sick  Children,  Toronto.) 

attached,  made  of  cheese-cloth  or  flannel  and  cotton  batting. 
(Fig.  174.)  Diapers  are  often  omitted  in  caring  for  very  feeble 
babies,  a  pad  of  cotton  being  slipped  under  the  buttocks  instead 
as  this  may  be  changed  with  less  disturbance  to  the  baby  than 
a  diaper. 


512  OBSTETRICAL  NURSING 

His  bed  consists  of  a  box  or  basket,  with  the  bottom  well 
padded  with  several  inches  of  cotton,  a  small  pillow  or  a  soft 
blanket  folded  to  the  proper  size,  covered  with  rubber  or  oiled 
muslin  and  a  cotton  sheet.  The  sides  of  the  basket  should  be 
lined  with  heavy  quilted  material  (Fig.  175),  to  shut  out  drafts 
and  help  to  preserve  an  even  temperature  of  the  air  immediately 
around  the  baby.  A  flannel  covered  hot-water  bag  at  110°  F. 
may  be  placed  beside  the  baby,  or  two,  three  or  four  glass  bot- 
tles, each  holding  about  a  pint,  containing  water  at  100°  F.  and 
securely  stoppered,  may  be  hung  in  the  corners  of  the  basket. 
(Fig.  176.)  A  thermometer  should  hang  in  the  basket  also,  and 
the  temperature  kept  between  80°  F.  and  90°  F.  It  is  easier  to 
keep  the  temperature  even  if  the  bottles  are  filled  in  rotation 
instead  of  all  at  the  same  time. 

The  amount  of  heat  needed  around  the  baby  is  decided  by 
taking  his  temperature  (by  rectum)  at  regular  intervals;  sup- 
plying more  heat  if  the  temperature  is  low  and  less  if  it  is  at 
or  above  normal.  Some  doctors  have  the  temperature  taken 
every  four  hours;  others  twice  daily.  As  the  baby  grows  able 
to  maintain  a  temperature  of  98°  F.  to  100°  F.,  unassisted,  the 
surrounding  heat  is  gradually  reduced  and  finally  removed,  and 
flannel  clothing  replaces  the  quilted  robe. 

In  many  hospitals  there  are  special  rooms  for  premature 
babies,  which  are  divided  by  glass  partitions  into  cubicles  so 
that  each  baby  is  in  a  three-sided  enclosure.  The  rooms  are 
usually  darkened  to  save  the  baby  from  the  needless  irritation 
of  light,  and  are  supplied  with  constantly  changing  fresh,  moist, 
filtered  air,  the  temperature  being  kept  at  from  80°  F.  to  90°  F. 

In  a  patient 's  home  or  in  a  hospital  where  there  is  no  special 
room  for  premature  babies,  a  cubicle  may  be  improvised  by  plac- 
ing the  basket  in  which  the  baby  lies,  in  the  corner  of  a  room 
and  placing  a  screen  parallel  with  one  of  the  walls.  Such  a 
room  should  be  darkened,  well  ventilated  and  have  in  it  a  large 
open  vessel  of  water. 

Since  the  premature  baby's  lungs  are  not  fully  expanded, 
respirations  are  likely  to  be  shallow  and  irregular,  thus  failing 
to  supply  the  amount  of  oxygen  which  he  sorely  needs.  As  cry- 
ing inevitably  involves  deep  breathing,  it  is  a  common  practice 


NURSING  CARE  OF  AVERAGE  NEW-BORN  BABY     513 

to  make  the  premature  baby  cry  at  regular  intervals  during  the 
day  in  order  to  promote  the  respiratory  function.  Dr.  Griffith 
further  recommends  plunging  the  baby  into  a  mustard  bath  at 
100°  F.  or  105°  F.  if  necessary  to  make  him  cry  vigorously.  It 
is  also  important  to  turn  the  premature  baby  from  side  to  side, 
several  times  a  day  to  prevent  fluid  from  collecting  in  the  lower- 
most part  of  the  lung,  a  condition  favorable  to  the  development 
of  pneumonia. 

In  feeding  premature  babies,  breast  milk  is  ordinarily  the 
most  desirable  food.  If  the  baby  is  too  feeble  to  nurse,  as  fre- 
quently occurs,  the  milk  may  be  expressed  from  the  breast  of 
his  mother  or  a  wet  nurse,  by  stripping  or  pumping,  into  a  sterile 
receptacle,  and  if  not  used  immediately  it  should  be  covered  and 
placed  in  the  refrigerator.  Breast  milk  is  sometimes  used  whole 
and  sometimes  diluted  with  water,  and  is  given  by  gavage  if 
the  baby  is  very  feeble ;  from  a  medicine  dropper  or  a  special 
feeder.  Such  a  feeder  consists  of  a  glass  tube  with  a  small  nipple 
on  one  end  and  a  rubber  bulb  on  the  other,  by  means  of  which 
the  milk  may  be  gently  expressed  into  the  baby's  mouth,  thus 
minimizing  his  etfort  to  obtain  it.     (See  Fig.  175.) 

The  amount  and  intervals  for  feeding  the  premature  baby 
have  to  be  adjusted  to  the  individual  with  even  greater  care 
than  for  a  normal  baby,  for  he  needs  more  fuel  and  building 
material,  because  of  his  imperfect  development  and  yet  because 
of  that  same  imperfect  development  his  digestive  powers  are 
feebler  than  those  of  the  full-term  baby.  During  the  first  day 
or  two,  he  is  sometimes  given  nothing  but  water  or  sugar  solu- 
tion, the  milk  being  started  gradually  when  the  baby  is  from 
thirty-six  to  forty-eight  hours  old.  He  may  be  given  a  very 
small  quantity  every  two  hours,  or  he  may  be  fed  at  three-  or 
four-hour  intervals,  depending  entirely  upon  his  condition  and 
progress.  It  is  usually  considered  very  important  for  the  pre- 
mature baby  to  have  sterile  water  or  sugar  solution  to  drink 
between  feedings,  and  this  is  given  in  the  same  manner  as  his 
milk. 

Unlike  the  normal  baby  he  is  not  taken  from  his  bed  to  be 
fed,  unless  he  nurses  at  the  breast. 

The  premature  baby  is  weighed  as  often  as  is  safe  for  hira, 


514  OBSTETRICAL  NURSING 

since  the  suitability  of  his  food  is  largely  indicated  by  changes 
in  his  weight.  But  sometimes  very  young  and  feeble  babies  are 
weighed  only  once  or  twice  a  week  because  of  the  inadvisability 
of  disturbing  them  more  frequently. 

Avoidance  of  fatigue  and  the  conservation  of  the  premature 
baby's  limited  strength  and  energy  are  accomplished  through 
reducing  his  muscular  activity  to  the  minimum,  by  very  little 
and  very  gentle  handling ;  and  by  minimizing  his  loss  of  energy 
in  the  form  of  heat  by  keeping  the  little  body  warm  and  quiet. 

In  this  connection  the  daily  bath  is  of  considerable  impor- 
tance. It  almost  always  consists  of  sponging  the  baby  with  warm 
olive  oil  as  he  lies  in  his  bed,  and  with  the  least  possible  ex- 
posure and  turning.  It  is  given  every  day  or  every  second  or 
third  day  according  to  his  condition.  The  eyes  are  wiped  with 
boric  pledgets  and  the  nostrils  with  spirals  of  cotton  dipped 
in  oil.  The  buttocks  are  wiped  with  an  oil  sponge  each  time  the 
diaper  is  changed. 

The  premature  baby  is  very  susceptible  to  infection  and 
strongly  predisposed  to  pneumonia.  Infection  in  general  is 
guarded  against  by  having  everything  that  comes  in  contact 
with  the  baby  scrupulously  clean;  protecting  him  from  drafts, 
chilling  and  dust;  allowing  no  one  with  a  suspicion  of  a  cold 
to  come  near  him  and  by  the  nurse's  wearing  a  clean  gown  and 
protecting  her  nose  and  mouth  with  a  gauze  mask  while  attend- 
ing him. 

CARE  OF  THE  BABY  DURING  THE  SUMMER 

The  dangers  of  infancy  are  greatly  increased  in  summer, 
more  babies  dying  during  the  hot  months  than  any  other  time 
during  the  year.  The  cause  of  these  deaths  is  variously  termed 
summer  complaint,  summer  diarrhea,  acute  gastro-enteritis  and 
cholera  infantum,  and  is  due  to  infected  or  decomposing  food 
or  both. 

Clearly  this  malady  is  practically  preventable  through  care. 

Although  such  care  as  has  been  described  in  the  preceding 
pages  largely  constitutes  the  prevention  of  the  much-to-be- 
dreaded  summer  diarrhea,  there  are  a  few  extra  precautions 


NURSING  CARE  OP^  AVERAGE  NEW-BORN  BABY      515 

and  safeguards  with  which  the  nurse  must  surround  her  little 
patient  during  the  warm  weather. 

She  must  bear  in  mind  the  character  of  the  illness  to  be 
avoided :  indigestion  associated  with  infection. 

It  becomes  almost  a  matter  of  life  or  death,  then,  to  give  the 
baby  clean,  suitable  food  and  avoid  deranging  his  digestion. 

Babies  suffer  from  the  heat  more  than  adults  do  and  are 
often  excessively  irritated  and  exhausted  on  warm  days.  And 
this  overheating,  exhaustion  and  restlessness  are  of  themselves 
enough  to  affect  his  digestion. 

Accordingly  the  scourge  of  summer  diarrhea  is  prevented 
by  giving  the  baby  proper  food  and  keeping  him  clean,  cool  and 
quiet. 

The  baby  should  have  maternal  nursing  if  possible,  for  breast- 
fed babies  fall  victim  to  summer  diarrhea  much  less  frequently 
than  bottle-fed  babies.  He  should  be  fed  with  absolute  regu- 
larity, and  as  a  rule,  no  matter  what  the  nature  of  his  food,  it  is 
reduced  one-quarter  to  one-third  in  amount  during  very  warm 
weather  and  he  is  given  an  increased  amount  of  cool  boiled  water 
to  drink.  His  weight  may  increase  very  slightly,  or  even  stand 
still  for  a  short  time,  as  a  result  of  his  decreased  food,  but  this 
is  not  usually  deplored,  if  he  keeps  well,  for  the  important  thing 
is  to  avoid  digestive  disturbances  while  the  weather  is  warm. 

Cleanliness,  as  at  other  times,  applies  to  the  baby's  food, 
clothing  and  surroundings.  Many  doctors  think  it  safer  to  have 
all  milk  boiled  during  the  summer,  and  of  course  require  flaw- 
less technique  in  its  preparation  and  administration.  The  baby 's 
soiled  napkins  should  be  placed  immediately  in  a  covered  re- 
ceptacle containing  water,  and  not  left  for  even  a  moment  where 
they  can  be  reached  by  flies.  They  should  be  washed,  boiled  and 
dried  in  the  open  air  and  sunshine  as  promptly  as  possible. 

The  baby  should  be  protected  from  flies  and  mosquitoes  by 
screens  in  the  windows  and  netting  over  his  crib  and  carriage, 
both  because  they  make  him  restless  and  irritable  and  because 
flies  particularly  are  carriers  of  filth  and  disease — the  kind  of 
disease  that  kills  so  many  babies  during  the  summer.  Accord- 
ingly the  nurse  must  always  regard  flies  with  a  deadly  fear. 

The  baby  should  be  kept  away  from  dusty  places  and  from 


516  OBSTETRICAL  NURSING 

cats  and  dogs.  And  since  babies  will  put  their  fingers  in  their 
mouths  it  is  a  wise  precaution  to  wash  their  hands  several  times 
a  day. 

The  baby  should  be  in  the  country,  in  the  mountains  or  at 
the  seashore  if  possible  during  the  warmest  part  of  the  summer 
at  least,  but  if  he  is  in  town  there  is  much  that  the  nurse  can 
do  to  keep  him  cool  and  comfortable.  His  clothing  at  this  time 
must  be  adjusted  to  his  condition  and  the  temperature  of  the 
moment  just  as  it  is  in  cold  weather.  A  thin  shirt,  band,  diaper 
and  cotton  slip  will  usually  be  enough  for  out-of-door  wear, 
while  in  the  house  he  may  often  dispense  with  the  slip  and 
sometimes  with  everything  but  his  diaper. 

During  excessively  hot  days,  the  baby  should  have  two  or 
three  cool  sponge  baths,  in  addition  to  the  soap  and  water  bath, 
one  of  the  sponges  being  given  before  he  is  put  to  bed  for  the 
night.  He  should  sleep  on  a  firm  mattress,  preferably  curled 
hair  but  never  feathers,  and  in  the  coolest,  best  ventilated  room 
available.  During  the  day  it  is  usually  best  to  take  him  out-of- 
doors  early  in  the  morning  and  late  in  the  afternoon,  but  to 
keep  him  indoors  during  the  warmest  part  of  the  day,  when  it 
is  likely  to  be  cooler  indoors  than  out,  particularly  if  the  blinds 
are  closed.  Quite  naturally  the  nurse  will  have  to  take  into 
consideration  the  size,  arrangement  and  location  of  the  baby's 
home  in  her  effort  to  keep  him  in  cool,  quiet,  shady  places  and 
out-of-doors  as  much  as  possible. 

He  must  not  be  played  with,  held  on  hot  laps  nor  subjected 
to  the  entertainment  and  attention  which  misguided  but  well- 
meaning  mothers  and  friends  are  so  eager  to  lavish  on  a  hot, 
fretful  baby. 

Very  often  during  warm  weather  a  fine  rash  known  as 
"prickly  heat"  appears  on  the  back  of  the  baby's  neck  and 
spreads  over  his  head,  neck,  chest  and  shoulders.  This  rash  is 
due  to  too  warm  clothing  or  to  the  hot  weather  or  to  both.  Less 
clothing  and  frequent  baths  will  often  give  relief,  but  if  the  baby 
is  very  uncomfortable,  he  may  be  greatly  soothed  by  being  im- 
mersed in  cool  baths  containing  soda,  bran  or  starch  in  the  fol- 
lowing proportions: 


NURSING  CARE  OP  AVERAGE  NEW-BORN  BABY      517 

Soda  bath.  Two  tablespoonfuls  of  baking  soda  to  one  gallon  of 
water. 

Bran  bath.  A  cheese-cloth  bag-  about  six  inches  square,  partly 
filled  with  bran,  is  soaked  and  squeezed  in  the  bath  water  until  it  is 
milky. 

Starch  bath.  About  eight  ounces  of  cooked  laundry  starch  to 
one  gallon  of  water. 

No  soap  should  be  used  while  the  baby  has  prickly  heat  and 
after  the  bath  he  should  be  patted  thoroughly  dry  and  powdered 
with  some  such  soothing  powder  as  the  following: 

Powdered    starch    one  ounce 

Oxide  of  zinc   one  ounce 

Boracic  acid  powder 60  grains 

As  we  look  back  over  these  pages  of  somewhat  detailed  de- 
sciiption  of  the  case  of  the  baby,  it  is  borne  in  upon  us  that  the 
nursing  of  this  unfailingly  delightful  and  interesting  little 
patient  has  special  adjustments  and  adaptations  for  different 
seasons  and  circumstances ;  but  that  on  the  whole  the  care  of  all 
babies  the  year  around  resolves  itself  into  the  observation  of 
a  few  general  principles,  namely :  proper  feeding ;  fresh  air ; 
regularity  in  his  daily  routine ;  cleanliness  of  food,  clothing  and 
surroundings ;  maintenance  of  an  equable  body  temperature  and 
conservation  of  his  forces. 

If  the  nurse  fixes  these  principles  firmly  in  her  mind  and 
acts  upon  them,  she  will  do  a  great  deal  to  give  her  baby  patient 
a  fair  start  on  his  life's  journey. 


CHAPTER  XXIII 

COMMON  DISORDERS  AND  ABNORMALITIES  OF 
EARLY  INFANCY 

The  common  ills  of  early  infancy  are  due  largely  either  to 
errors  in  feeding  or  to  infection  or  both.  Of  the  nutritional 
disturbances,  rickets  and  scurvy  were  discussed  in  the  chapter 
on  nutrition,  but  the  obstetrical  nurse  will  sometimes  see  also, 
malnutrition,  marasmus,  inanition,  diarrheal  diseases,  acidosis^ 
colic,  constipation  and  vomiting. 

All  of  these  disorders  are  practically  preventable  through 
suitable  feeding,  good  care  and  hygienic  surroundings.  The 
nurse's  part  in  this  prevention  consists  in  giving  the  painstak- 
ing care  which  was  described  iii  the  preceding  chapter. 

The  terms  malnutrition,  marasmus,  and  inanition  designate 
different  forms  and  degrees  of  starvation,  and  are  characterized 
by  loss  of  weight,  prostration,  feeble  powers  of  assimilation, 
general  weakness  and  arrested  growth.  The  temperature  is 
likely  to  be  low,  but  in  acute  inanition,  a  rapid  loss  in  weight 
may  be  accompanied  by  a  sudden  rise  in  temperature.  (Charts 
6,  7,  and  8.) 

These  so-called  "wasting  diseases"  are  frequently  seen  in 
children  who  have  congenital  nervous  instability  and  those  born 
of  tuberculous,  syphilitic  or  otherwise  delicate  parents.  The 
treatment  is  suitable  food ;  fresh  air  and  sunshine ;  an  abundance 
of  fluid  by  mouth,  rectum,  subcutaneously  or  intraperitoneally ; 
clean  surroundings  and  good  nursing  care. 

THE  DIARRHEAL  DISEASES 

These  are  among  the  most  frequent  and  most  serious  illnesses 
of  early  infancy.  They  may  result  from  mechanical  causes,  such 
as  a  mass  of  undigested  food,  which  produces  increased  intestinal 
secretion  and  peristalsis;  from  the  action  of  bacteria,  or  their 
toxins,  together  witli  the  inability  of  an  enfeebled  digestive  tract 

518 


DISORDERS  OF  EARLY  INFANCY  519 

to  meet  the  needs  of  a  rapidly  growing  body ;  or  from  such  reflex 
causes  as  sudden  chilling  of  the  body,  excitement,  fatigue  or 
the  prostration  resulting  from  excessively  hot  weather. 

Acute  gastro-enteritis,  the  dian-heal  disease  which  is  so  com- 
mon and  so  fatal  during  the  hot  months  of  July  and  August,  is 
often  referred  to  as  "summer  complaint"  or  "summer  diar- 
rhea." It  is  so  largely  avoidable  through  good  nursing  that  the 
methods  of  its  prevention  were  described  in  connection  with  the 
care  of  the  baby  during  the  Summer,  resolving  itself,  as  it  does, 
into  feeding  the  baby  properly  and  keeping  him  clean  and  cool 
and  quiet. 

Symptoms.  While  there  are  different  forms  of  summer 
diarrhea,  the  general  symptoms  are  much  the  same  and  may 
develop  gradually  after  some  evidence  of  indigestion,  or  sud- 
denly with  a  rise  of  temperature  to  101°  F.  or  102°  F.,  or  even 
as  high  as  106°  F.,  accompanied  by  pain  and  vomiting.  The 
baby  is  usually  restless,  fretful  and  thirsty  and  his  skin  is  hot 
and  dry.  He  gives  evidence  of  pain  by  shrill  crying,  drawing 
up  his  legs  and  flexing  them  on  his  abdomen.  Diarrhea  is  the 
conspicuous  symptom  and  there  may  be  anywhere  from  four 
to  twenty  movements  in  the  course  of  24  hours.  The  stools  are 
largely  fecal  matter  at  first  but  they  finally  become  fluid  and 
contain  mucus.  They  may  be  expelled  with  a  good  deal  of 
force  and  a  quantity  of  gas  come  with  them.  The  baby  grows 
very  weak,  thin  and  hollow-eyed,  if  the  diarrhea  persists  and 
unless  promptly  treated  the  end  may  be  fatal. 

Treatment  and  Nursing  Care.  The  first  step  is  to  stop  all 
food  and  to  give  water  freely.  When  water  is  not  retained  by 
mouth  it  is  frequently  given  by  rectum,  into  the  tissues  or  intra- 
peritoneally.   The  pain  may  be  relieved  by  applying  hot  stupes. 

Feeding  is  resumed  very  gi'adually  and  cautiously  for  one 
attack  of  summer  complaint  predisposes  to  another  and  every 
precaution  is  taken  to  prevent  a  recurrence.  Thin  barley  water 
or  broth  is  usually  given  first,  followed  by  whey,  protein  milk, 
buttermilk  or  diluted  skim-milk  in  small  amounts  and  at  com- 
paratively long  intervals. 

The  baby  should  be  lightly  clad;  should  be  kept  quiet  and 
in  a  cool,  shady  place  out-of-doors  as  much  as  possible.    During 


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fi2n 


DISORDERS  OF  EARLY  INFANCY 


521 


the  warmest  part  of  the  day,  however,  he  will  often  be  much 
better  off  and  more  comfortable  in  the  house,  in  a  room  with 
the  shutters  closed.  But  while  keeping  the  baby  cool,  the  nurse 
must  bear  in  mind  the  harm  that  will  be  done  by  chilling  him 
or  exposing  him  to  a  cold  draft  or  Avind.  Several  tub  baths, 
daily,  are  often  given,  at  a  temperature  of  100°  F.,  rather  than 
cool  sponge  baths  because  of  the  baby's  feebleness  and  inability 
to  react  to  cool  bathing.  Packs  are  also  employed,  both  for 
high  temperature  and  restlessness  and  may  be  cool   (80°  F.), 


Fig.  177. — Putting  the  baby  in  a  wet  pack. 


tepid  (100°  F.)  or  hot  (105°  F.  to  108°  F.)  according  to  the 
doctor 's  orders ;  intestinal  irrigations ;  lavage  and  gavage. 

To  give  a  pack,  the  nurse  will  cover  the  bed  with  a  rubber 
and  sheet  and  bring  to  the  bedside  a  basin  containing  a  sheet 
wrung  from  water  of  the  specified  temperature ;  a  basin  contain- 
ing ice  and  compresses  for  the  baby's  head,  and  a  flannel  covered 
hot-water  bottle  at  120°  F.,  for  his  feet.  The  baby  is  laid  on 
the  upper  half  of  the  folded  wet  sheet,  and  an  upper  corner 
wrapped  about  each  arm  (Fig.  177),  and  the  sides  folded  around 
his  legs.  The  lower  half  is  brought  up  between  his  feet  to  cover 
his  entire  body  and  tuck  around  his  shoulders.     The  hot-water 


522 


OBSTETRICAL  NURSING 


bottle  is  placed  at  his  feet  and  an  ice  compress  on  his  head.  (Fig. 
178.)  If  the  sheets  are  wrung  from  warm  or  hot  water,  the 
baby  is  covered  with  a  blanket  after  he  is  put  into  the  pack. 


Fig.  178. — Baby  in  pack  with  hot -water  bag  at  feet  and  cold  compress 
on  head.  (Figs.  177  and  178  from  photographs  taken  at  Johns  Hopkins 
Hospital. ) 

Intestinal  irrigations,  of  normal  salt  solution  are  often  given 
to  babies  suffering  from  intestinal  disorders,  sometimes  once  or 
twice  daily  to  wash  out  the  lower  bowel,  or  a  cool  irrigation  may 
be  given  to  reduce  temperature,  the  amounts  varying  from  i/^  to 


Corner's  o^  sheet. 
uJrQpped  .around  arms 


Loojer  holf  o|  sVieel 
taken  up  betuueen 
legs  (feet  not 
covered) to  cover 
body  completely 
and  is  tucWed  under 
shoulders 


Sides  of  sheet 
wrapped  around  IsflS 


Fig.  179. — Diagrams  showing  successive  steps  in  putting  baby  in  pack 
shown  in  Figs.  177  and  178. 


DISORDERS  OF  EARLY  INFANCY  523 

2  gallons  of  solution.  The  baby  should  be  placed  on  a  pillow 
and  rest  on  a  bed-pan,  being  protected  from  chilling  as  for,  an 
enema  (See  Fig.  186),  and  provision  made  for  a  two-way  flow  of 
the  fluid.  A  small  catheter  attached  by  means  of  a  connecting 
glass  nozzle  to  the  tubing  on  the  irrigation  bag  may  be  passed 
into  a  slightly  larger  catheter,  which  is  inserted  into  the  rectum 


Fig.  ISO. — Baby  wrapped  in  blanket,  before  being  given  gavage  or  eye 
irrigation,  to  keep  him  warm  and  hold  his  arms  and  legs  to  his  sides. 
(From  photograph  taken  at  Johns  Hopkins  Hospital.) 

about  six  inches,  the  fluid  flowing  in  through  the  small  inner 
tube  and  out  through  the  larger  one  which  encases  it.  Or  a  small 
catheter  for  the  outflow  may  be  inserted  in  the  rectum  along- 
side the  one  through  which  the  solution  is  introduced.  Normal 
salt  solution,  glucose  or  bicarbonate  of  sodium  solution  are  some- 
times given  by  the  drip  method  at  the  rate  of  20  to  40  drops 
per  minute.  In  this  case  a  glass  tube  is  introduced  at  some  point 
in  the  rubber  tubing  in  order  that  the  rate  of  flow  may  be 


524 


OBSTETRICAL  NURSING 


watched  and  regulated  by  means  of  a  clamp  or  a  stop-cock.  The 
catheter  is  inserted  in  the  rectum  about  six  inches  and  held  in 
place  by  strips  of  adhesive  plaster. 

LavBige  and  Gavage.     Sometimes  when  the  baby  vomits  per- 
sistently the  stomach  is  washed  out  and  a  small  amount  of  water 


Fig.  181. — Gavage.     (From  photograph  taken  at  Johns  Hopkins  Hospital.) 


or  nourishment  given  before  the  tube  is  withdrawn.    A  tray  con- 
taining the  following  articles  should  be  carried  to  the  bedside: 

A  glass  funnel  attached  to  a  rubber  tubing  which  connects  with  a 
small  rubber  catheter  by  means  of  a  glass  nozzle. 
Basin  to  receive  stomach  contents. 

Small  rubber,  towel  and  curved  basin  to  x^laee  under  baby's  chin. 
Glass  graduate  containing  warm  water  for  washing  out  stomach. 


DISORDERS  OF  EARLY  INFANCY  525 

Food  or  solution  which  is  to  remain  in  stomach,  standing:  in  cup 
of  warm  water. 

Glj'cerin  to  hibricate  tube. 

Mouth  gag,  if  necessary,  or  roll  of  bandaf::e  to  hold  jaws  apart. 

The  baby  should  be  wrapped  tightly  (Fig.  180)  to  prevent 
interference' bj^  his  struggling  and  turned  slightly  to  the  left  side. 
(Fig.  181.)  The  catheter  is  lubricated  Avith  glycerin  or  water 
and  passed  back  over  the  tongue  and  quickly  downward  until 
an  air  bubble  is  heard  as  it  enters  the  stomach.  The  length  of 
tubing  which  is  to  be  inserted  may  be  anticipated  by  marking 
a  point  on  the  tube  which  is  the  same  distance  from  the  end  as 
the  baby's  mouth  is  from  its  umbilicus.  The  possibility  and 
the  serious  consequences  of  introducing  the  tube  into  the  trachea 
instead  of  into  the  esophagus  must  be  borne  in  mind.  Although 
the  baby  Avill  often  choke  and  struggle  when  the  tube  is  properly 
introduced,  he  will  not  cough  violently  and  stop  breathing  as 
he  will  if  it  enters  the  air  passage.  Further  information  is  ob- 
tained by  inverting  the  funnel  in  a  basin  of  water  after  the  tube 
is  inserted ;  if  it  is  in  the  stomach  there  will  be  no  result,  but  if 
it  is  in  the  trachea  air  will  be  expelled  and  bubbles  will  rise 
through  the  water.  To  wash  out  the  stomach,  the  funnel  is  filled 
with  warm  water  and  slighth^  raised  so  that  the  water  will  run 
in  slowly,  after  which  the  funnel  is  turned  upside  down  into 
a  basin  which  is  lower  than  the  baby's  body,  and  the  stomach 
contents  allowed  to  run  out.  This  is  repeated  four  or  five  times, 
or  until  the  solution  returns  clear,  and  the  food  which  is  to  re- 
main in  the  stomach  is  poured  in  slowly.  Before  the  tube  is 
quite  empty  it  is  pinched  off  with  the  fingers  and  quickly  with- 
drawn. 

Acidosis.  The  diarrheal  diseases  are  sometimes  complicated 
by  acidosis,  a  condition  in  which  the  relative  amounts  of  acid 
in  the  blood  are  so  increased  that  the  normal  alkalinity  is 
markedly  diminished.  This  condition  may  result  from  an  ex- 
cessive intake  of  acids ;  an  overproduction  of  acids  in  the  course 
of  normal  metabolism ;  a  decrease  in  the  reserve  of  normal  alkali 
in  the  body  or  a  failure  in  the  mechanism  by  means  of  which 
excessive  acids  are  usually  neutralized  or  eliminated.  Acidosis 
is  a  serious  complication  and  often  fatal. 


526 


OBSTETRICAL  NURSING 


The  treatment  is  directed  toward  preventing  the  production 
of  more  acids  within  the  body ;  restoring  the  alkali  reserve  and 
promoting  elimination  of  the  excessive  acids  and  their  salts. 
Solutions  of  glucose,  bicarbonate  of  sodium  and  salt  are  used 
and  are  given  by  mouth,  rectum,  intravenously  and  intraperi- 
toneally.  Subcutaneous  injections  are  not  wholly  satisfactory, 
because  of  the  small  amounts  which  may  be  given  in  this  way. 


Fig.  182. — Method  of  obtaining  a  fresh  specimen  of  urine  in  a  test  tube. 

From  150  to  400  cubic  centimetres  are  given  into  the  peritoneal 
cavity  and  as  the  solution  absorbs  readily  these  injections  are 
sometimes  repeated  every  eight  or  twelve  hours,  an  infusion  bot- 
tle and  short  infusion  needle  being  used.  From  75  to  300  cubic 
centimetres  of  glucose  solution  (5  per  cent,  or  10  per  cent.)  is 
given  intravenously,  while  as  much  as  1000  cubic  centimetres  is 
sometimes  given  per  rectum  in  the  course  of  24  hours  by  the  drip 
method.  Soda  solution  (4  per  cent.)  is  often  given  by  mouth, 
if  the  baby  is  able  to  retain  it,  or  intravenously,  as  frequently 
as  the  condition  of  the  urine  indicates  is  necessary.     From  75 


DISORDERS  OF  EARLY  INFANCY 


527 


to  100  cubic  centimetres  is  ^iven  at  one  time  to  young  babies. 

In  preparing  the  soda  solution  it  must  be  remembered  that 

boiling  drives  off  carbonic  acid  and  forms  sodium  carbonate  and 


I  iG.  183. — Obtaining  a  24-hour  specimen  of  urine  through  curved  glass 
tube  attached  to  rubber  tubing  which  empties  into  bottle  tied  to  side  of 
bed.     (From  photographs  taken  at  Johns  Hopkins  Hospital.) 

that  its  reconversion  into  sodium  bicarbonate  is  a  complicated 
procedure.     Howland  and  Marriott  ^   say   in   this  connection : 


Fig.  184. — Muslin  band  with  cuffs  and  tape  used  to  keep  the  baby  from 
kicking  while  a  specimen  of  urine  is  being  obtained.  The  tapes  are  tied 
tightly  to  the  sides  of  the  crib  and  the  cuffs  fastened  around  the  baby's 
ankles  with  safety  pins.     See  Figs.  182  and  183. 

"Oscar  Schloss  has  found  that  sodium  bicarbonate  in  bulk  is 

always  sterile.     It  is  probably  therefore  sufficient  to  add  the 

bicarbonate  with  proper  precautions  to  sterile  water." 

'"Acidosis,"  by  John  Howland,  M.D.,  and  W.  McKim  Marriott,  M.D., 
Pennsylvania  Medical  Journal,  April,  1918. 


528 


OBSTETRICAL  NURSING 


Since  the  results  of  urine  tests  frequently  indicate  the  treat- 
ment in  acidosis,  it  is  of  very  great  importance  that  the  nurse 
be  able  to  obtain  specimens  from  young  babies.  (Figs.  182,  183, 
184  and  185  for  methods  of  obtaining  fresh  and  24-hour  speci- 
mens from  babies.) 

Colic,  Constipation,  Convulsions  and  Vomiting  so  frequently 
seen  in  young  babies  are  symptoms  rather  than  diseases. 

Colic  usually  consists  of  paroxysms  of  pain  in  the  stomach 
or  intestines,  due  to  distension  or  to  spasmodic,  muscular  con- 
tractions. The  indirect  cause  may  be  unsuitable  food  or  food 
given  too  rapidly;  chilling  of  the  surface  of  the  body,  excite- 
ment or  fatigue.  The  distension  may  be  due  to  air  swallowed 
by  the  baby  while  nursing  or  gas  formed  by  carbohydrate  fermen- 


Fig.  185. — Belt  used  to  hold  tube  in  place  while  obtaining  specimen  of 
urine  as  indicated  in  Figs.  182  and  183.  The  tube  is  passed  through  the 
hole  in  the  tab  and  adjusted  over  penis  or  between  labia;  the  belt  fastened 
around  the  waist  and  straps  passed  between  the  thighs  and  fastened  to  belt. 

tation.  Excess  of  protein  may  form  an  irritating  mass  in  the 
intestines  and  cause  a  cramp. 

While  colic  frequently  accompanies  malnutrition  and  con- 
stipation, it  is  often  seen  in  otherwise  well  and  happy  babies, 
and  usually  before  the  fifth  month.  The  attacks  are  usually  sud- 
den and  may  occur  several  times  a  day  after  feeding,  or  only  in 
the  late  afternoon  or  at  night.  The  baby  cries  shrilly;  his  face 
is  drawn  and  may  be  flushed,  from  crying,  or  cyanotic ;  his  fists 
are  clenched  and  pressed  to  his  body  and  his  feet  and  hands  are 
cold.  His  abdomen  is  hard  and  distended  and  during  a  pain  the 
baby  flexes  his  thighs  upon  it  and  afterAvard  extends  them  with  a 
jerk.  This  painful  seizure  may  last  only  a  few  moments  or 
it  may  persist  for  hours,  leaving  the  baby  exhausted. 

The  chief  preventive  measures  are  found  in  the  precautions 
and  attention  to  detail  which  have  been  described,  and  which 


DISORDERS  OF  EARLY  INFANCY  529 

should  be  included  in  the  care  of  all  babies.  In  a  bottle-fed 
baby  it  is  often  found  that  recurrence  of  attacks  of  colic  may  be 
averted  by  a  slight  change  in  the  milk  formula ;  by  giving  more 
water  to  drink;  by  lengthening  the  intervals  between  feedings; 
by  giving  the  milk  more  slowly  or  by  omitting  the  2  a.m.  feeding, 
thus  giving  the  baby  more  digestive  rest. 

Witli  breast-fed  babies,  prevention  is  often  accomplished  by 
having  the  mother  nurse  her  baby  more  slowly,  lengthening 
the  intervals  and  by  improving  her  own  hygiene;  particularly 
by  increasing  her  recreation  and  out-of-door  exercise  and  re- 
lieving constipation.  Women  who  lead  sedentary  lives  and  eat 
rich  food  very  often  have  colicky  babies  as  do  those  who  are 
nervous,  irritable  and  inclined  to  worry.  (See  chapter  on  the 
nursing  mother.) 

When  attacks  of  colic  occur,  the  pain  usually  may  be  relieved 
by  giving  half  of  a  soda-mint  tablet  in  a  little  warm  water  and 
an  enema  of  about  eight  ounces  of  soap-suds  or  salt  solution 
at  110°  F.,  given  through  a  small  catheter  inserted  about  six 
inches.  The  baby  will  experience  almost  immediate  relief 
through  the  expulsion  of  gas  and  feces  and  he  may  be  made  still 
more  comfortable  by  placing  a  hot-water  bag  at  his  cold  feet; 
rubbing  his  abdomen  with  vaselin  and  applying  hot  stupes. 
Sometimes  the  first  feeding  which  falls  due  after  an  attack  is 
omitted  and  a  little  warm  water  or  barley  water  is  given  in- 
stead, in  order  that  the  digestive  tract  may  rest. 

Constipation  is  very  common  among  young  infants  and  may 
be  manifest  by  the  stools  being  too  small,  too  dry  or  too  infre- 
quent.   The  commonest  causes  are  : 

1.  Faulty  diet — possibly   too  much  protein  or  too  httle  fat  or 
sugar. 

2.  Intestinal  atony,  due  to  undernourishment,  rickets  or  anemia. 

3.  Anal  fissure  which   makes  the  baby  unwilling  to  empty  his 
bowels  because  of  pain. 

4.  Absence  of  habit  of  emptying  the  bowels  regularly. 

The  prevention  of  this  very  troublesome  condition  lies  largely 
in  suitable  food;  constant  fresh  air;  regularity  in  the  daily 
routine  and  training  the  baby  to  empty  his  bowels  at  the  same 
time  every  day. 


530 


OBSTETRICAL  NURSING 


When  constipation  is  due  to  insufficient  fat  in  the  food,  cod- 
liver  oil  is  sometimes  given,  15  to  30  drops  three  or  four  times 
a  day  J  or  a  teaspoonful  of  olive  oil  two  or  three  times  a  day. 
Maltose,  malt  soup,  malted  milk,  milk  of  magnesia,  liquid  petro- 
latum, oatmeal-water  and  orange  juice  are  all  found  among  the 
remedies  for  constipation;  while  soap  sticks,  suppositories  and 
enemata  of  oil  or  soap-suds  sometimes  have  to  be  resorted  to. 


Fig.  186. — Giving  an  enema.  The  baby  lies  comfortably  on  a  pillow 
which  reaches  to  the  bed  pan,  the  latter  being  covered  with  a  diaper  where 
the  baby  rests  upon  it.     He  is  well  protected  to  prevent  chilling. 

In  giving  an  enema  to  relieve  constipation,  the  baby  should 
be  protected  from  chilling,  laid  on  a  pillow  and  the  pan  so  placed 
that  he  will  be  comfortable  and  not  inclined  to  move,  and  from 
100  to  300  cubic  centimetres  of  soap-suds,  at  105°  F.,  given  with 
a  small  hard-rubber  nozzle.  (Fig.  186.)  When  warm  olive  oil 
is  given  at  night  (1  to  2  ounces  through  a  catheter  introduced 
about  6  inches),  it  is  very  often  retained  and  the  feces  so  softened 
that  the  baby  empties  his  bowels  freely  the  next  morning  with 
little  or  no  assistance. 

Abdominal  massage  will  often  help  to  increase  the  intestinal 


DISORDERS  OF  EARLY  INFANCY  531 

tone  and  make  peristalsis  more  vigorous.  The  abdomen  should 
be  rubbed  with  a  circular  stroke,  beginning  in  the  right  groin  and 
following  the  course  of  the  colon  up  to  the  margin  of  the  ribs, 
across  to  the  left  side  and  down  to  the  groin.  This  is  often  given 
for  about  ten  minutes  every  day,  preferably  at  night  but  never 
just  after  a  feeding. 

Constipation  is  sometimes  entirely  cured  by  a  suitable 
dietary ;  an  abundance  of  drinking  water ;  an  out-of-door  life ; 
massage,  and  above  all,  the  unremitting  effort  to  establish  a  regu- 
lar habit.  The  latter  is  the  nurse 's  responsibility  and  she  should 
exercise  the  greatest  patience  in  trying  to  accomplish  the  desired 
end. 

Convulsions  are  a  symptom  of  several  disorders  of  early  in- 
fancy, which  may  occur  unexpectedly  rnd  which  the  nurse  may 
suddenly  be  called  upon  to  relieve  in  the  absence  of  the  doctor. 
Convulsions  may  be  due  to  brain  lesions;  to  spasmophilia  or  a 
special  tendency  to  convulsive  disorders;  gastro-intestinal  disor- 
ders; toxemia  or  syphilis.  They  may  be  the  initial  symptom 
of  an  acute  infectious  disease  or  may  occur  on  slight  provocation 
in  a  frail,  undernourished  baby  or  one  suffering  from  rickets  or 
tetany.  For  this  reason  one  sometimes  sees  convulsions  in  a 
baby  who  is  teething  ur  has  colic  or  indigestion. 

As  convulsions  are  a  symptom  of  some  abnormal  condition, 
the  doctor  will  often  prescribe  a  sustained  treatment  designed 
to  remove  or  relieve  the  cause.  But  when  an  attack  occurs  un- 
expectedly, and  tha  doctor  cannot  come  at  once,  the  nurse  may 
often  terminate  the  seizure  by  employing  measures  that  will 
quiet  and  relax  the  struggling  baby.  The  room  should  be  quiet 
and  darkened  and  the  baby  handled  with  utmost  gentleness  be- 
cause of  the  extreme  irritability  of  his  nervous  system.  As  a 
rule,  the  most  satisfactory  course  is  to  immerse  the  baby  in  water 
at  100°  F.,  and  keep  him  there  for  five  or  ten  minutes,  support- 
ing his  head  and  shoulders  meantime.  Someone  else  should  place 
cold  compresses  on  his  head  and  change  them  frequently.  When 
removed  from  the  bath,  the  baby  should  be  wrapped  in  a  blanket, 
kept  very  quiet  and  the  cold  applications  to  his  head  continued. 

When  it  is  known  that  the  convulsions  are  due  to  indigestion 
the  stomach  is  often  washed  out  and  a  high  colonic  irrigation 


532  OBSTETRICAL  NURSING 

^ven  before  the  baby  is  quieted  by  the  bath.  In  tetanoid  con- 
vulsions the  baby  may  take  a  long  deep  inspiration  and  fail  to 
expire.  Respirations  should  be  stimulated,  in  such  a  case,  by 
spanking  him  sharply  or  by  dashing  cold  water  on  his  face  and 
chest.  When  the  attacks  are  recurrent  the  nurse  may  be  in- 
structed to  terminate  them  by  giving  the  baby  a  few  whiffs  of 
chloroform,  which,  with  an  inhaler  is  kept  in  readiness  for  in- 
stant use. 

Mustard  baths  and  packs  are  sometimes  given  when  the  need 
for  counter  irritation  is  indicated.  For  a  bath,  one  ounce,  or 
six  level  tablespoonfuls  of  dry  mustard  is  added  to  one  gallon 
of  water  at  105°  F.  and  the  baby  kept  in  it  for  about  ten  min- 
utes, or  until  the  skin  is  well  reddened.  He  is  then  wrapped  in 
a  warm  blanket  and  surrounded  by  hot-water  bottles,  with  cold 
compresses  applied  to  his  head.  The  mustard  pack  is  given  in 
the  manner  of  other  packs,  with  a  sheet  wrung  from  mustard 
water  which  is  possibly  a  little  warmer  and  stronger  than  that  for 
the  bath,  caye  being  taken  that  the  sheet  is  not  cooled  before  it 
is  wrapped  about  the  baby.  He  is  usually  left  in  the  pack  for 
about  ten  minutes  or  until  his  skin  is  reddened,  and  then  wrapped 
in  warm  blankets,  with  cold  compresses  to  his  head. 

It  is  often  helpful  to  the  doctor  if  the  nurse  is  able  to  describe 
the  onset  of  the  convulsions  and  tell  him  where  the  twitching 
began,  how  it  progressed  and  whether  or  not  it  was  preceded 
by  a  cry. 

Vomiting  during  early  infancy  is  a  symptom  of  any  one  of 
several  conditions,  the  nature  of  which  sometimes  may  be  re- 
vealed by  the  character  of  the  attacks.  The  commonest  causes 
and  varieties  of  vomiting  are  as  follows: 

1.  Too  rapid  feeding  or  too  large  amounts  of  food  given  at  one 
time.  The  vomiting  amounts  to  little  more  than  regurgitation  and  is 
often  induced  by  moving  or  handling  the  baby  immediately  after  feed- 
ing him. 

2.  Acute  gastric  indigestion.  Sour  stomach  contents  may  be 
vomited  immediately  after  feeding,  or  not  until  several  hours  later  and 
may  be  followed  by  mucus  and  bile.  The  baby  is  usually  pale,  par- 
ticularly about  the  mouth;  he  may  perspire  about  the  forehead  and 
give  evidence  of  pain,  being  relieved  by  the  vomiting. 

3.  Stenosis  of  the  pylorus.     The   vomiting  from   this   cause   is 


DISORDERS  OF  EARLY  INFANCY  533 

projectile  in  character  and  may  occur  immediately  after  food  is  taken 
into  tlie  stomach,  or,  some  time  later  without  apparent  cause,  a  larger 
amount  of  fluid  may  be  expelled  than  was  given  at  the  preceding  fe_ed- 
ing.  The  vomiting  may  begin  a  few  days  after  birth  or  several  weeks 
afterwards  in  a  baby  who  has  been  well  previously. 

4.  Intestinal  obstruction  due  to  congenital  obstruction,  which 
causes  persistent  vomiting  from  birth ;  or  due  to  intussusception  of 
the  intestines,  when  vomitus  consists  first  of  stomach  contents  which 
later  becomes  bile  stained  and  sometimes  contains  fecal  matter,  blood 
and  mucus.  It  is  attended  by  prostration,  and  after  fecal  matter  is 
passed  at  the  beginning,  there  is  frequent  evacuation  of  blood  and 
mucus. 

5.  Chronic  or  habit  vomiting,  sometimes  occurring  in  early  in- 
fancy, may  be  difficult  to  control  because  of  being  incited  by  such 
slight   causes   as   laughing,   crying  or  being  moved. 

In  addition  to  being  caused  by  the  above  mentioned  condi- 
tions, vomiting  in  young  babies  may  usher  in  an  acute  infectious 
disease,  as  a  chill  does  in  an  adult,  or  it  may  accompany  such 
diseases  as  peritonitis,  meningitis,  brain  tumors  and  toxic  con- 
ditions such  as  uremia, 

INFECTIONS 

The  infectious  diseases  which  the  obstetrical  nurse  is  most 
likely  to  see  in  her  baby  patient  are  ophthalmia  neonatorum; 
syphilis ;  impetigo ;  pemphigus  and  vaginitis. 

Ophthalmia  Neonatorum,  intiammation  of  the  eyes  of  the 
new-born  or  "babies'  sore  eyes,"  is  one  of  the  common  diseases 
of  infancy  and  certainly  one  of  the  most  dreaded  because  of  the 
tragedy  of  lifelong  blindness  which  may  follow  in  its  wake.  In 
the  early  days  of  organized  work  for  the  prevention  of  blind- 
ness the  term  "ophthalmia  neonatorum"  implied  a  gonorrheal 
infection,  but  it  is  now  known  that  inflamed  eyes  and  subse- 
quent blindness  may  result  from  infection  of  innocent  origin. 
Accordingly,  in  those  states  where  it  is  required  that  the  disease 
be  reported,  ophthalmia  neonatorum  is  defined  as  inflammation 
of  the  eyes  of  new-born  babies,  irrespective  of  the  cause.  The 
disease  is  frequently  due  to  the  gonococcus,  the  baby 's  eyes  being 
infected  from  the  mother  during  passage  through  the  birth 
canal  or  infected  later  by  her  hands  or  clothing.  Or  the  in- 
flammation may  be  caused  by  the  streptococcus,  pneumococcus 


534  OBSTETRICAL  NURSING 

or  the  colon,  diphtheria  or  influenza  bacilli  while  very  fre- 
quently the  infection  is  mixed. 

It  is  estimated  that  about  20  out  of  every  1000  new-born 
babies  have  sore  eyes,  and  though  many  of  the  infections  are 
mild,  between  5  and  8  of  these  20  cases  are  capable  of  becoming 
serious  and  causing  blindness  if  not  speedily  and  skillfully 
treated.  The  number  of  cases  which  are  neglected  is  suggested 
by  the  fact  that  about  10  per  cent,  of  all  blindness,  the  world 
over,  is  due  to  infant  ophthalmia  and  that  about  20  per  cent,  of 
the  inmates  of  schools  for  the  blind  in  this  country  are  sightless 
from  this  cause.  This  does  not  take  into  account  the  unnum- 
bered army  of  those  who  are  partially  blind,  or  blind  in  one 
eye,  and  thus  seriously  handicapped,  as  a  result  of  this  disease. 

Symptoms.  The  first  symptoms  are  redness  and  swelling 
of  the  lids,  usually  accompanied  by  a  discharge  of  pus  from  the 
beginning,  and  they  ordinarily  appear  during  the  first  few  days 
of  life,  but  sometimes  develop  as  late  as  the  second  or  third 
week.  The  disease  may  run  a  very  rapid  course  and  cause  blind- 
ness in  48  hours  from  the  time  the  first  symptoms  appear,  or  it 
may  persist  for  weeks.  Ulceration  of  the  cornea  is  the  dreaded 
consequence  of  the  inflammation  as  ulcers  are  followed  by  scars. 
When  the  scar  is  small,  or  to  one  side  of  <he  pupil,  there  may 
be  little  or  no  impairment  of  vision,  but  if  it  is  large  and  cen- 
trally located  it  forms  an  opaque  screen  and  causes  blindness 
by  shutting  out  the  light,  although  the  interior  of  the  eye  behind 
the  scar  is  sound  and  uninjured.  Sometimes  the  ulcer  causes 
a  perforation  of  the  cornea  through  which  the  lens  and  vitreous 
humor  are  discharged. 

Attempts  have  been  made  to  remove  the  scar  following  a 
centrally  located  ulcer  and  replace  it  with  a  clear  cornea  from 
some  such  animal  as  a  guinea  pig,  but  the  operation  apparently 
has  not  been  perfected.  When  it  is,  many  blind  persons  may 
have  their  sight  restored  to  them. 

Prevention.  It  may  be  stated  almost  without  qualification 
that  ophthalmia  neonatorum  is  a  preventable  and  curable  dis- 
ease, and  accordingly  that  blindness  from  this  cause  is  inexcus- 
able. Prevention  lies  first,  in  wiping  the  baby 's  eyes  immediately 
after  birth  and  instilling  a  drop  or  two  of  a  silver  salt,  such  as 


DISORDERS  OP  EARLY  INFANCY  535 

nitrate  of  silver,  argyrol  or  protargol,  or  bathing  them  with 
boracic  acid  solution;  and  second,  in  close  watching  for  early 
symptoms  and  giving  speedy  treatment  when  they  appear.  This 
is  urgent  because  there  is  no  way  of  determining  in  the  begin- 
ning whether  the  infection  is  mild  or  virulent.  Nitrate  of  silver 
solution,  1  per  cent.,  is  the  prophylactic  most  commonly  em- 
ployed and  its  use  is  now  routine  in  most  hospitals  and  in  the 
practices  of  many  physicians  in  this  country.  The  solution  is 
sometimes  dropped  between  the  baby's  lids,  immediately  after 
the  birth  of  the  head,  and  before  the  birth  of  the  entire  body, 
and  sometimes  immediately  after  delivery  is  completed.  Many 
doctors  follow  the  silver  drops  with  normal  salt  solution  to  pre- 
vent the  slight  silver  catarrh  which  so  frequently  occurs  other- 
wise, and  which  may  be  confused  with  early  symptoms  of 
ophthalmia.  Still  others  prefer  simply  to  bathe  the  eyes  with 
boracic  acid  solution  (unless  they  know  that  the  mother  has 
gonorrhea)  and  to  watch  them  closely  for  the  slightest  redness, 
swelling  or  discharge  and  give  prompt  treatment  if  these  appear. 

The  Crede  method,  made  famous  by  the  Viennese  obstetrician 
who  introduced  it  in  1881,  was  to  drop  from  a  glass  rod,  a  single 
drop  of  nitrate  of  silver,  2  per  cent.,  into  each  eye  immediately 
after  birth.  The  routine  use  of  this  prophylaxis  reduced  the 
occurrence  of  ophthalmia  in  Crede 's  clinics  from  10  per  cent, 
to  .1  per  cent,  among  the  new-born  babies. 

Since  it  is  now  believed  that  close  vigilance  and  subsequent 
care  are  equally  as  important  as  the  prophylactic  drops,  the 
Crede  treatment  has  been  variously  modified  and  other  and 
weaker  silver  solutions  are  frequently  used,  and  with  satisfactory 
results.  The  dropping  of  a  germicide  into  the  baby's  eyes  kills 
the  organisms  which  may  be  present  at  the  time,  but  it  does  not 
protect  against  subsequent  infection.  For  this  reason  the  nurse 
cannot  be  charged  too  earnestly  to  watch  the  baby's  eyes  closely 
for  the  first  evidence  of  infection,  and  report  it  to  the  doctor 
immediately,  day  or  night,  for  the  late  infections  are  as  destruc- 
tive of  sight  as  those  which  occur  before  or  during  birth. 

Treatment  aaid  Nursing  Care.  The  treatment  and  nursing 
care  in  ophthalmia  frequently  require  the  greatest  skill.  There 
may  be  merely  an  application  of  silver  and  sponging  with  boracic 


536 


OBSTETRICAL  NURSING 


acid  solution  or  a  gentle  irrigation  with  a  blunt  nozzle  (Fig. 
187),  or  the  preservation  of  the  baby's  sight  may  necessitate 
dressings  and  treatment  which  will  require  elaborate  preparation 
(Fig.  188),  and  may  also  require  some  form  of  treatment  every 
quarter-  or  half -hour,  day  and  night  and  occupy  the  entire  time 
of  two  or  three  special  nurses.    The  nurse 's  duties  in  caring  for 


Fig.  187. — Irrigating  the  eye  with  a  blunt  nozzle,  the  irrigation  bag 
hanging  low  in  order  that  the  stream  may  be  gentle.  (From  a  photograph 
taken  at  Johns  Hopkins  Hospital.) 


the  eyes  will  be  explicitly  defined  by  the  doctor,  but  in  general 
she  must  remember  that  she  is  nursing  a  baby  suffering  from 
an  acutely  infectious  disease,  who  should  be  strictly  isolated, 
and  that  as  a  rule  she  should  wear  a  gown,  rubber  gloves  and 
protective  goggles  while  caring  for  him.  All  of  her  attentions 
to  the  inflamed  eyes  must  be  given  with  the  greatest  gentleness 
in  order  to  avoid  abrasion  of  the  conjunctiva  or  injury  of  the 
cornea.    Moreover,  the  baby  with  suppurative  conjunctivitis  is 


DISORDERS  OF  EARLY  INFANCY 


537 


Fig.  188. — Method  of  holding  baby  for  eye  examination  or  treatment. 
(Photograph  and  appended  notes  by  courtesy  of  Dr.  W.  Gordon  M.  Beyers, 
Eoyal  Victoria  Hospital,  Montreal.) 

"The  child's  bodj-  is  swathed  in  a  sheet  or  blanket  in  such  a  way  that  the  arms  are 
lightly,  but  securely,  fixed  against  the  sides.  The  nurse  can  easily  support  the  body 
with  one  hand,  and  with  the  other  draw  down  the  lower  lid  (as  shown  in  the  photograph), 
or  otherwise  assist  the  physician.  The  doctor  sits  opposite  the  nurse,  with  a  rubber 
sheet  across  his  knees,  and  upon  this  a  sterile  towel.  He  holds  the  baby's  head  gently, 
but  firmly,  between  his  knees,  thus  freeing  both  his  hands  for  necessary  manipulations. 
In  the  picture  the  physician  is  represented  as  about  to  apply  a  solution  of  nitrate  of 
silver  with    an  applicator  of   sterile   absorbent   cotton. 

"Close  at  hand  is  a  table  on  which  are  a  bowl  of  boracic  acid  solution  and  sterile 
absorbent  cotton  for  irrigating  the  eyes  ;  an  undine  (if  one  prefers)  for  the  same  purpose  ; 
a  kidney  dish  for  collecting  the  washings ;  sterile  applicators,  and  small  dishes  for 
nitrate  of  silver  solution  and  for  saline  solution  (to  neutralise)  :  besides  bottles  containing 
solutions  of  cocaine,  atropine,  and  fluorescein.  Culture  tubes,  sterile  swabs,  cover  slips, 
forceps,  and  a  spirit  lamp  are  ready  for  bacteriological  examinations ;  and  in  a  glass  are 
displayed  lid  retractors,  which  are  usually  indispensable  to  a  thorough  examination  of 
the  cornea.  On  the  floor  is  a  paper  bag,  which,  with  the  contaminated  swabs,  applicators, 
etc.,  is  burned  on  the  completion  of  the  treatment.  Other  articles  may  be  added  as 
required ;  but  the  important  point  is,  that  everything  should  be  at  hand  before  the 
examination  is  begun. 

"The  physician  and  the  nurse  are  clothed  in  surgical  gowns  ;  and  wear  rubber  gloves, 
which  heighten  cleanliness,  and  safety  and  comfort.  It  is  to  be  carefully  noted  that 
they  both  are  provided  with  protective  glasses ;  for  under  no  circumstances  should  this 
precaution  be  omitted  in  treating  the  purulent  ophthalmias. 

"The  conditions  here  depicted  will  not  always  be  possible  of  fulfilment,  but  they 
represent  the  ideal  for  which  one  should  strive." 


538  OBSTETRICAL  NURSING 

a  sick  baby  often  fighting  for  his  life  as  well  as  his  sight,  and 
every  effort  must  be  made  to  preserve  his  strength  and  increase 
his  resistance.  Fresh  air  and  careful  feeding  are  imperative. 
Breast-fed  babies  have  a  distinct  advantage  over  bottle-fed  babies 
and  for  this  reason  the  mother  should  always  accompany  the 
nursing  baby  if  he  is  taken  from  his  home  to  a  hospital  to  be 
treated  for  ophthalmia  neonatorum,  unless  there  is  a  wet  nurse 
available  at  the  hospital. 

It  is  of  interest  to  nurses  that  the  effort  to  safeguard  the 
eyes  of  babies  through  preventive  treatment  and  early  care  was 
developed  into  a  national  movement  by  one  who  also  was  influ- 
ential in  starting  the  training  of  nurses  in  this  country,  Miss 
Louisa  Lee  Schuyler.  The  lay  work  for  the  prevention  of  blind- 
ness, which  is  now  country-wide,  was  started  by  the  New  York 
State  Committee  for  Prevention  of  Blindness,  which  was  or- 
ganized by  Miss  Schuyler  in  1908.  She  was  its  first  Chairman 
and  skillfully  directed  the  work  of  the  Committee  for  ten  years. 
During  the  Civil  War  Miss  Schuyler  was  a  member  of  the  Sani- 
tary Commission  and  afterwards  was  one  of  the  group  which 
was  responsible  for  starting  at  Bellevue  Hospital,  in  New  York 
City  (in  May,  1873),  the  first  training  school  for  nurses  in  this 
country,  planned  in  accordance  with  Miss  Nightingale's  stand- 
ards for  the  organization  and  conduct  of  a  school  for  nurses. 
Later,  in  1911,  the  Bellevue  School  for  Midwives  was  estab- 
lished as  a  result  of  the  combined  efforts  of  the  Hospital  Trus- 
tees and  Miss  Schuyler 's  Committee  for  Prevention  of  Blindness, 
the  course  of  training  being  outlined  by  a  sub-committee  com- 
posed of  Miss  Lillian  D.  Wald,  Dr.  J.  Clifton  Edgar  and  myself. 
So  far  as  it  is  possible  to  learn  this  school  was  the  first  in  this 
country  to  be  conducted  along  the  lines  of  a  school  for  nurses, 
or  after  the  manner  of  the  midwife  schools  in  England. 

Syphilis,  which  ranks  high  among  the  scourges  of  mankind, 
is  seen  with  distressing  frequency  among  young  babies.  It  may 
be  contracted  during  uterine  life,  when  it  is  said  to  be  ''in- 
herited," or  it  may  be  "acquired"  after  birth  by  kissing  a 
syphilitic  person  or  coming  in  contact  with  contaminated  articles, 
such  as  clothing,  or  nursing  from  a  diseased  breast. 


DISORDERS  OF  EARLY  INFANCY  53S 

The  most  conspicuous  symptoms  are  the  familiar  "snuffles;" 
the  scaling,  fissures  or  eruption  on  the  soles,  palms,  buttocks  and 
about  the  mouth;  shrill,  hoarse  crying;  swollen  painful  joints; 
partial  paralysis  and  a  general  feebleness  and  inanition.  Some 
or  all  of  these  symptoms  may  be  present  when  the  baby  is  born 
or  they  may  develop  any  time  within  the  first  two  or  three 
months  of  life. 

Babies  of  syphilitic  mothers  are  often  given  mercurial  in- 
unctions immediately  after  birth,  even  though  they  have  no 
symptoms  of  the  disease  as  it  is  very  likely  to  be  present  in  a 
latent  form.  This  is  one  reason  for  the  routine  inspection  of 
the  placenta,  since  in  it  is  sometimes  found  the  only  indication 
for  treating  the  baby.  An  infant  who  is  known  to  have  syphilis 
is  given  mercurial  inunctions  or  baths,  the  ointment  being  rubbed 
into  the  groin,  axilla,  back  and  abdomen  in  rotation  on  succes- 
sive days,  to  prevent  irritation  of  the  skin.  The  nurse  should 
protect  herself  with  rubber  gloves,  wash  the  area  with  warm 
water  and  soap  and  thoroughly  rub  in  the  ointment.  Sometimes 
the  ointment  is  put  on  the  inside  of  the  back  of  the  baby's  binder, 
by  which  means  he  rubs  it  in  himself.  The  syphilitic  baby  should 
be  isolated  and  should  not  be  put  to  the  breast  of  an  uninfected 
woman,  but  he  may  nurse  from  a  syphilitic  woman  without  harm 
to  either  her  or  himself.  Good  general  care,  including  fresh  air 
and  sunshine  are  important  to  the  baby  suffering  from  syphilis. 

Thrush  or  Sprue  is  a  highly  communicable  disease  of  the 
mouth  of  new-born  babies,  due  to  one  of  the  fungi.  It  is  com- 
mon among  sickly,  undernourished  babies  and  those  living  in 
unhygienic  surroundings,  but  it  is  seldom  seen  in  healthy  babies 
who  are  cared  for  with  absolute  cleanliness.  The  disease  is  char- 
acterized by  small  raised,  white  spots  in  the  baby's  mouth,  fre- 
quently on  the  back  of  the  tongue  and  inner  surface  of  the 
cheeks. 

Prevention  lies  in  good  care  and  in  cleanliness  of  the  mother 's 
nipples,  or  the  bottles  and  nipples  for  artificially  fed  babies,  and 
of  all  other  articles  coming  in  contact  wath  the  baby,  particu- 
larly his  mouth.  Some  doctors  have  the  baby's  mouth  bathed 
before  each  feeding,  as  a  preventive  measure,  while  others  feel 


540  OBSTETRICAL  NURSING 

that  a  gentle  swabbing  once  daily  is  sufficient,  if  the  nipples  are 
kept  clean,  since  an  abrasion  of  the  mucous  lining  is  easily 
caused  and  is  favorable  to  the  development  of  thrush. 

Treatment  consists  in  cleanliness  and  in  gently  swabbing  the 
spots,  three  or  four  times  a  day,  with  sterile  cotton  wet  with  an 
alkaline  solution  such  as  borax  (10%),  bicarbonate  of  sodium 
(6%)  and  sometimes  with  formalin  {!%)  or  a  weak  solution  of 
permanganate  of  potassium. 

Impetigo  and  Pemphigus  are  highly  infectious  skin  diseases 
of  early  infancy  which  are  seen  more  often  in  hospitals  than  in 
patients'  homes.  The  treatment  of  the  raised  blisters  that  ap- 
pear on  different  parts  of  the  body  is  entirely  a  medical  ques- 
tion, but  in  caring  for  the  patients  suffering  from  either  of  these 
infections  the  nurse  must  take  every  precaution  to  avoid  ex- 
tending the  trouble  on  the  skin  of  the  infected  baby,  himself, 
and  of  communicating  it  to  other  babies  in  the  ward.  Strict 
isolation  is  imperative;  gentle  handling  and  frequent  changing 
of  the  underclothing  to  prevent  extending  the  disease  to  unin- 
fected areas. 

Vaginitis.  This  highly  infectious  malady  is  considered 
troublesome  rather  than  serious,  as  a  rule,  though  it  may  be 
complicated  by  ophthalmia  or  arthritis.  Gonorrheal  vaginitis  is 
the  commonest  form  seen  in  early  infancy  and  may  be  due  to 
infection  which  the  baby  acquired  during  its  passage  through 
the  birth  canal  or  later  from  the  mother's  hands  or  clothing. 
The  symptoms  are  a  vaginal  discharge,  which  may  be  thin  and 
serous  or  thick  and  yellow  and  purulent  and  it  may  be  scanty 
in  amount  or  abundant;  a  reddened,  swollen  condition  of  the 
vagina  and  vulva  and  sometimes  redness  and  excoriation  of 
the  inner  surface  of  the  thighs.  The  nurse's  chief  responsibili- 
ties are  to  be  constantly  on  the  alert  to  detect  evidences  of  the 
disease  and  report  them  promptly  to  the  doctor,  and  to  observe 
strict  isolation  in  caring  for  the  baby  while  carrying  out  the 
doctor's  orders  for  douches  or  suppositories. 

COMMON  ABNORMALITIES   OF   THE   NEW-BORN 

Icterus  or  Jaundice,  which  is  so  frequently  seen  in  new-born 
babies,  is  occasionally  a  symptom  of  some  septic  condition;  of 


DISORDERS  OF  EARLY  INFANCY  541 

syphilis  or  congenital  cirrhosis  of  the  liver  or  obstruction  of 
the  bile  ducts,  but  as  a  rule  it  is  without  any  serious  significance. 
The  jaundiced  appearance  usually  begins  on  the  second  or  third 
day  and  may  continue  for  two  or  three  weeks  or  it  may  subside 
in  three  or  four  days.  The  depth  of  the  color  varies,  being  very 
pale  in  some  cases  and  almost  green  in  others.  When  this  dis- 
coloration of  the  skin  is  unaccompanied  by  other  symptoms,  no 
treatment  is  given. 

A  Cephalhematoma  is  a  tumor  of  blood  between  the  peri- 
osteum and  the  bones  of  the  skull  of  the  new-born  baby.  It  is 
often  due  to  some  injury  sustained  during  birth  and  is  most 
frequently  seen  after  prolonged  labors.  Cephalhematoma  is 
sometimes  confused  with  a  caput  succedaneum,  but  whereas  the 
caput  disappears  in  a  few  days  the  cephalhematoma  may  not  be 
entirely  absorbed  for  two  or  three  months.  Although  certain 
conditions  sometimes  indicate  the  advisability  of  surgical  treat- 
ment, the  nurse's  care  consists  solely  of  protecting  the.  tumor 
from  injury. 

Club  foot  is  one  of  the  commonest  deformities  of  the  extremi- 
ties of  young  babies,  occurring  once  in  about  every  1000  births. 
It  may  be  congenital  or  caused  by  injury  or  it  may  be  due  to 
such  diseases  as  cerebral  paralysis  or  poliomyelitis.  The  nurse 
should  watch  for  any  abnormality  in  the  structure  or  position  of 
the  feet,  for  the  earlier  treatment  is  started,  the  better  is  the 
prospect  of  a  cure. 

Engorgement  of  the  Breasts.  Not  infrequently  the  breasts 
of  new-born  babies  are  engorged,  in  which  state  they  are  easily 
infected  by  being  rubbed  or  squeezed.  Since  the  greatest  care 
must  be  taken  to  avoid  bruising  swollen  breasts,  they  are  some- 
times protected  by  the  application  of  a  pad  of  sterile  cotton. 
Hot  compresses  are  sometimes  applied  when  there  is  redness 
with  the  swelling,  or  a  tiny  ice-bag,  made  by  tying  off  the  fingers 
and  thumb  of  a  rubber  glove,  and  partly  filling  it  with  finely 
crushed  ice,  after  which  the  wrist  is  tightly  tied. 

Hare  Lip.  The  fissured  lip,  which  is  not  infrequently  seen 
in  new  babies,  may  consist  merely  of  a  small  notch  or  it  may 
amount  to  a  deep  cleft  reaching  up  into  the  nostril.  It  is  due 
to  a  non-union  of  the  fronto-nasal  plate  with  the  lateral  processes 


542  OBSTETRICAL  NURSING 

and  may  occur  on  one  or  both  sides,  thus  forming  a  single  or 
double  hare  lip.  An  extensive  fissure  will  usually  interfere 
with  suckling  and  the  nurse  may  need  both  ingenuity  and  pa- 
tience in  feeding  such  a  baby,  for  the  prospect  of  successful 
treatment,  which  is  surgical,  increases  with  the  baby's  age  and 
improved  nutrition.  The  longer  she  can  feed  the  baby  success- 
fully, therefore,  the  better  his  chance  of  recovery. 

Cleft  palate,  a  common  congenital  abnormality,  consists  of 
a  fissure  of  the  soft,  and  sometimes  of  the  bony,  palate ;  it  may 
be  on  one  or  both  sides  and  may  be  continuous  with  a  hare  lip. 
The  problem  of  feeding  the  baby  with  a  cleft  palate  is  very  grave 
since  the  fissure  may  make  it  impossible  for  him  to  form  the 
vacuum  in  the  back  of  his  mouth  which  is  necessary  for  suck- 
ling. He  is  sometimes  fed  with  a  medicine  dropper  or  by  gavage 
or  by  means  of  a  special  nipple  provided  with  a  flap  which  fits 
into  the  roof  of  the  mouth  and  closes  the  opening  into  the  nasal 
passages.  Even  more  than  in  the  care  of  the  baby  with  a  hare 
lip  is  it  important  to  nourish  the  baby  with  a  cleft  palate,  and 
build  him  up  for  as  long  as  possible  before  he  is  subjected  to  the 
strain  and  shock  of  the  inevitable  operation. 

Hernia.  Umbilical  and  inguinal  hernias  are  both  seen  in 
young  babies. 

Umbilical  hernia  is  the  commoner  type  and  is  not  uncommon 
in  thin  babies  and  those  with  indigestion  and  distension  and 
in  babies  who  cry  violently.  Such  hernias  are  not  regarded  as 
serious  if  prompt  measures  are  taken  to  reduce  them  as  they 
usually  respond  very  readily  to  treatment.  But  since  neglect 
may  have  serious  consequences,  the  nurse  should  watch  for  pro- 
trusions and  report  them  promptly.  She  will  often  be  instructed 
to  reduce  the  hernia  and  apply  adhesive  strapping,  in  which 
case  the  following  observations  by  Dr.  Griffith  will  be  helpful: 

* '  Usually  it  is  quite  sufficient  to  draw  the  skin  into  two  folds, 
one  on  each  side  of  the  hernia  and  meeting  over  it ;  holding  these 
in  place  by  straps  of  adhesive  plaster  crossing  over  the  navel,  or 
by  a  broad  horizontal  band  of  adhesive  plaster  reaching  to  the 
lumbar  regions.  Another  method  is  the  following:  A  silver 
quarter  of  a  dollar  is  laid  upon  the  adhesive  surface  of  a  piece 
of  rubber  plaster  about  two  inches  square;  over  this  is  placed 


DISORDERS  OF  EARLY  INFANCY  543 

the  broad  strap  referred  to,  with  its  adhesive  surface  next  to 
that  of  the  smaller  piece.  After  reducing  the  hernia  and  press- 
ing the  sides  of  the  abdominal  walls  slightly  together  the  band 
is  applied  with  the  quarter  dollar  directly  over  the  position  of 
the  navel.  My  own  preference  is  for  a  simple  adhesive  band 
without  the  use  of  the  coin.  The  dressing  should  be  worn  con- 
stantly, changing  it  from  time  to  time  as  the  old  one  loosens. 
The  dressing  must,  of  course,  not  be  removed  during  the  bath. 
Several  months  are  required  before  the  opening  is  permanently 
closed.  Occasionally  the  plaster  produces  a  great  deal  of 
cutaneous  irritation,  especially  in  the  first  few  months  of  life. 
The  employment  of  zinc  oxid  plaster  tends  to  avoid  this  diffi- 
culty."^ 

Inguinal  hernia  is  less  common  in  very  young  babies  but  it 
should  be  watched  for  since  it  usually  may  be  easily  reduced 
by  the  use  of  a  truss,  if  discovered  and  treated  early,  but  may 
be  serious  if  neglected. 

In  general,  the  new  baby  who  is  ill,  needs  the  same  thought- 
ful, gentle,  painstaking  care  that  the  nurse  gives  to  the  well 
baby,  but  these  must  be  shaped  to  his  immediate  requirements 
and  the  doctor's  special  instructions. 

*"The  Diseases  of  Infants  and  Children,"  by  J.  P.  Crozer  Griffith,  M.D. 


CHAPTER  XXIV 
A  FINAL  WORD 

It  will  be  well  for  us  now  to  take  a  retrospective  view  of 
the  various  functions  of  the  nurse  which  are  associated  with 
the  phenomena  of  pregnancy,  labor,  the  puerperium  and  the 
beginning  of  a  new  life.  As  we  see  these  in  perspective,  our 
attention  is  fixed  by  a  few  important  principles  which  stand  out 
from  the  picture  as  a  whole  in  clear  and  shining  relief. 

"We  see,  for  example,  that  no  matter  what  else  may  become 
vague  and  unimportant,  be  changed  or  discarded,  there  remains 
the  conspicuous,  unalterable  requirement  that  the  nurse  shall 
do  clean  work  throughout  this  entire  series  of  experiences.  All 
maternity  patients  and  all  babies  need  scrupulously  clean  care 
no  matter  what  else  they  may  have  or  may  lack. 

But  also  must  they  all  be  watched  throughout  these  transi- 
tional stages,  in  order  that  impending  disaster  may  be  appre- 
hended and  warded  off.  And  that  this  watchfulness  be 
intelligent,  the  nurse  must  of  necessity  know  something  of 
the  normal  physiological  changes  which  occur  during  these 
momentous  periods  in  the  lives  of  her  patients,  lest  she  fail  to 
detect  evidence  of  abnormality,  should  it  appear. 

Since  this  invariable  cleanliness  and  close  watchfulness  are 
needed  by  all  patients,  whether  of  high  or  low  degree,  and 
by  those  in  the  care  of  doctors  with  widely  varied  methods, 
the  nurse  must  be  able  to  make  adaptations  to  each  patient's 
environment  and  temperament  and  to  the  doctor  as  well,  if  all 
of  her  patients  are  to  be  well  and  happily  nursed.  She  must  be 
clean,  then,  and  watchful  in  her  work,  and  adapt  it  to  every  con- 
ceivable condition.  These  features  stand  out  clear  and  bold  in 
the  perspective.  But  to  make  these  offices  effective  to  their 
utmost,  the  nurse's  attitude  and  her  care  of  her  patient  must  be 
mellowed  by  an  always  deepening  sympathy  and  understanding. 
She  must  endeavor,  in  each  instance,  to  imagine  the  mental  ex- 

544 


A  FINAL  WORD  545 

perience  of  the  bewildered  and  timid  expectant  mother;  of  the 
terrified  woman  in  labor  and  the  discouraged  young  mother — 
these  she  must  appreciate  if  she  is  to  give  of  her  best.  And  so,  in 
the  end,  the  character  of  the  nurse's  work  will  be  influenced,  in 
fact  almost  determined,  by  her  awareness  of  her  patient's 
needs,  mental  and  physical,  and  the  earnestness  with  which  she 
tries  to  relieve  them.  More  than  this,  the  nurse  whose  skill  is 
warmed  by  a  sincere  desire  to  give  of  her  best  will,  by  virtue  of 
this  very  desire,  learn  something  from  each  patient,  and  will  be 
steadily  enriched  and  broadened  by  her  experiences.  She  will 
have  more  to  give,  and  accordingly  will  derive  increasing  satis- 
faction from  her  service  to  each  succeeding  mother  and  baby  that 
she  takes  into  her  care. 

One  word  more.  The  maternity  nurse  almost  inevitably  be- 
comes deeply  attached  to  her  baby  patient,  whether  he  is  sick  or 
well,  and  she  is  eager  to  protect  him  and  safeguard  him  as  long 
as  possible.  She  may  continue  to  serve  him,  even  after  he  has 
passed  from  her  trained  hands,  if  she  will  teach  his  mother  how 
to  take  care  of  him,  should  she  be  inexperienced,  particularly  if 
the  young  mother  is  to  have  full  charge  of  her  baby  after  the 
nurse  leaves,  or  is  to  have  only  the  assistance  of  a  partly  trained 
nursery  maid.  In  such  a  case  the  nurse  may  often  perform  her 
most  valuable  and  enduring  service  to  the  baby  by  gradually 
teaching  his  mother  how  to  prepare  the  milk  with  cleanliness  and 
accuracy,  if  he  must  be  bottle-fed ;  how  to  give  his  bath  deftly  and 
comfortably,  and  impressing  upon  her  the  importance  of  fresh 
air  and  of  regularity  in  the  baby's  daily  routine.  All  of  these 
things,  and  also  how  to  do  the  thousand  and  one  other  things 
that  seem  so  trivial  and  yet  mean  so  much  to  the  baby's  im- 
mediate health  and  future  well  being. 

The  first  day  after  the  nurse  leaves,  and  the  first  few  after 
that  are  often  very  dark  ones  for  the  inexperienced  young 
mother,  and  if  she  is  alone  they  are  likely  to  be  filled  with 
fear  and  misgivings.  The  nurse  may  rob  these  days  of  much 
of  their  discouragement  by  anticipating  them ;  trying  to  imagine 
the  young  mother's  possible  perplexities  and  then  teaching  her 
how  to  meet  them.  This  teaching  is  perhaps  not  a  part  of  the 
nurse's  professional  obligation  but  it  is  one  of  the  privileges. 


546  OBSTETRICAL  NURSING 

one  of  the  gratifying  by-paths  of  nursing  that  she  may  take 
for  the  sheer  joy  of  it. 

Not  infrequently  the  young  mother  is  so  tilled  with  awe 
over  possessing  anything  so  wonderful  as  her  own  baby  that 
she  is  afraid  to  handle  the  exquisite  little  body;  is  fearful  of 
harming  it;  and  because  of  her  timidity  and  inexperience  she 
fails  to  give  him  the  care  that  he  needs,  and  that  she  wants 
to  give.  On  the  other  hand,  all  too  many  young  mothers  have  a 
blind  confidence  that  the  mere  act  of  having  a  baby  vests  one,  in 
some  instinctive  way,  with  the  requisite  knowledge  and  skill 
to  care  for  it,  and  in  this  belief  they  are  supported  by  a  legion 
of  women  friends  and  relatives. 

It  would  be  difficult  to  imagine  a  single  factor  that  works 
more  destruction  among  babies  than  this  one  of  ignorant 
motherhood.  And  the  damage  is  equally  great  whether  the 
ignorance  arises  from  timidity  or  from  overweening  confidence. 

"Is  it  not  preposterous,"  says  Herbert  Spencer,  ''that  the 
fate  of  a  new  generation  should  be  left  to  the  chance  of  un- 
reasoning custom,  impulse,  fancy,  joined  with  the  suggestions 
of  ignorant  nurses  and  the  prejudiced  counsel  of  grandmothers? 
To  tens  of  thousands  that  are  killed,  add  hundreds  of  thousands 
that  survive  with  feeble  constitutions,  and  millions  that  grow 
up  with  constitutions  not  so  strong  as  they  should  be,  and  you 
have  some  idea  of  the  curse  inflicted  on  their  offspring  by 
parents  ignorant  of  the  laws  of  life. ' ' 

The  nurse  is  in  the  most  effective  position  possible,  to  help 
in  dispelling  maternal  ignorance,  during  the  long  days  of 
pleasant  intimacy  which  she  and  the  young  mother  spend  to- 
gether in  devotion  to  the  baby.  And  by  helping  the  inex- 
perienced young  mother  to  give  skilful  care  to  her  baby,  with 
all  of  the  gentleness  and  tenderness  that  a  mother  can  lavish, 
the  nurse  will  not  only  serve  the  baby;  she  also  will  awaken 
for  many  a  young  woman,  an  interest  that  will  be  ever  fresh 
and  absorbing,  and  point  the  way  to  unexpected  joys  and  de- 
lights in  her  motherhood. 

"Can  there  be  any  higher  work  than  this? 
Can  any  woman  wish  for  a  more  womanly  work?" 


INDEX 


Abdomen,  changes  in,  during  preg- 
nancy, 102 

enlargement  of,  during  pregnancy, 
98 
Abdominal    binders,    in    pregnancy, 
122 

in  puerperium,  349 
Abdominal   palpation,    226 
Abdominal   pedicle,    76 
Abdominal  supporters,  in  pregnancy, 

122 
Abdominal  wall,  in  puerperium,  321 
Abnormalities  of  newborn,  540 
Abortion,  165,  166 

attempted,  151 

causes  of,  166 

complete,  170 

early  signs  of,  142 

incomplete,    170 

induced,  309,  and  see  Induced  ab- 
ortions 

missed,  170 

prevention  of,  168 

symptoms    of,    167 

therapeutics,  171 

threatened,  170 

treatment  of,  170 
complete,    170 
incomplete,  170 
threatened,  170 
Abscesses,  in  breast,  344 
Accidental  hemorrhage,  178 
Accidents   of   pregnancy,   164 
Accouchement  forc6,  309,  313 
Acidosis,    525 

Acute  yellow  atrophy  of  liver,  dur- 
ing  pregnancy,   207 
Advice  for  mothers,  427 
After -birth,  see  Placenta 
After-care,    immediate,    of    patient, 

281 
After-pains,  318 

Air,  fresh,  during  pregnancy,  129 
Albumen  in  urine,  tests  for,  118 
Alcohol,  during  pregnancy,  127 
Amenorrhea,  56 
Amnion,  70 

development  of,  70 
Amniotic   fluid,   71 
Analgesia,  nitrous  oxid  gas,  291 
Anatomy  of  pelvis  and  genitalia,  19 


Anesthesia,  h  la  reine,  288 

chloroform,   287,   288 

complete,   292,   293 

ether,   289,   290 

light,    288 

nitrous  oxid  gas,  291 

obstetrical,  286,  288 

scopolamin  and  morphin,  292 

unfavorable  signs  in,  294 
Animal  foods,  allowed  during  preg- 
nancy, 128 
Ante-partum  hemorrhage,  174 
Areolae,   43 

Artificial  feeding  of  baby,  489 
Attitude  of  fetus,  in  utero,  217 
Auscultation  of   fetal  heart,  231 
Axis-traction  forceps,  301 

Baby,  and  see  Infant,  and  New-born 
basket  for,  while  travelling,  507 
care  of,  by  visiting  nurse,  437 
during  summer,  514 
immediate,  265 
while  travelling,  507 
feeding,  486,  and  see  Baby's  food 
artificial,    489 
breast,  486 
giving  bottle  to,  495 
method  of  holding,  for  eye  exam- 
ination,  537 
nutrition  of,  368 
preparations  for,  162 
supplies    for,    428 
sore  eyes  of,  533 
toilet  tray  for,  417 
Baby 's  food,  articles  used  in  prepar- 
ing, 492 
commercial,  503 
ingredients  of,  498 
proprietary,   504 
Baby  basket,  for  travelling,  507 
Ballottement,   100 
Barley  water,  preparation  of,  505 
Bartholin's  glands,  40 
Bath,  bran,   preparation  of,  517 
in  puerperium,  329 
soda,  preparation  of,  517 
starch,  preparation  of,  517 
Bathing,   during  pregnancy,   119 
Baudelocque's  diameter,  25,  27 
Bed  exercise,  in  puerperium,  349 


547 


548 


INDEX 


Bed,  position  in  during  puerperium, 
326 
preparation  of  for  labor,  248 
Beef   juice,   preparation   of,   506 
Beri-beri,  376 

Binders,    abdominal,    during    preg- 
nancy, 122 
in  puerperium,  349 
for   breast,   123,    345,    347 
Birth,    changes   in   fetal   circulation 

at,  84,  87 
Bladder,  37 

care  of  in  puerperium,  332 
Blastodermic  vesicle,  65,  66 
Bleeding,  see  Hemorrhage 
Bones,  changes  in,  during  pregnancy, 

104 
Bottle,  giving  of  to  baby,  495 
Bowels,   care   of   in   pregnancy,   120 
care  of,  in  puerperium,  331 
of  fetus,  88 
Bradycardia,   puerperal,    322 
Bran  bath,  preparation  of,  517 
Bread,    allowed    during    pregnancy, 

128 
Breast,  and  see  Lactation,  and  Nur- 
sing 
abscess  in,  344 
anatomy   of,   41,   42 
binders,  in  pregnancy,  123 
in  puerperium,   345,   347 
caked,  344 
care  of,  during  pregnancy,  131 

in  puerperium,  339 
changes     in,     in     pregnancy,     96, 

103 
drying  up  of,  366 
feeding,    486,    and    see    Nursing, 
Lactation 
contraindications,  357 
infusion  under,  202 
stripping,  348 

supporting,  in  puerperium,  343 
supports  for,  in  puerperium,  343, 
345 
Breast  tray,  417 

Breath,    shortness   of,    during    preg- 
nancy,   140 
Breech  extraction,  298 
Bregma,  89 
Broad  ligament,  33,  38 
Broths,  preparation  of,  506 

Caesarean  section,  305 

conservative,    307 

extra-peritonealj  307 

indications  for,  306 

radical,    307 
Caked  breasts,  344 
Cane  sugar,  498 
Canned  milk,  504 


Caput    succedaneum,    differentiated 

from  cephalhematoma,  541 
Cardiovascular    system,    changes    in 

in  pregnancy,  103 
Care  of  baby,  by  visiting  nurses,  437 
in  traveling,  507 
during  summer,  514 
immediate,  265 
of  mother,  by  visiting  nurses,  437 
Carriage,  in  pregnancy,  105 
Catheterization,  333 
Cephalhematoma,  541 
Cereals    allowed    during    pregnancy, 

128 
Certified   milk,  490 
Cervix,  changes  in  in  pregnancy,  99, 
102 
during  labor,  234 
Champetier  de  Eibes'  bag,  311 
Childbirth,  deaths  in,  112,  405 
Chloasma,  97,  105 
Chloroform  anesthesia,  287,  288 
Chorion,    68 

development  of,  68 
frondosum,   70 
laeve,    70 
primitive,  67 
villi,    68,    70 
Circulation,  fetal,  84,  85 

changes  in  at  birth,  84,  87 
Cleft  palate,  in  new-born,  542 
Climacteric,  56 

Clinic  assistant,  duties  of,  431 
Clinic  equipment,  432 
Clitoris,   40 

Clothes,  during  pregnancy,  121 
Club  foot,  in  new-born,  541 
Coccyx,  20 
Colic  in  infants,  528 
Colonic  irrigations  in  eclampsia,  195 
Colostrum,   103 
Commercial  baby  foods,  503 
Complete  abortion,  170 
Complicated  labors,  295 
Complications  of  pregnancy,  164 
early  signs  of,   141,   143 
of  puerperium,  391 
Concealed  hemorrhage,  178 
Conception,  62 
Condensed  milk,  504 
Confinement,    to    calculate    date    of, 

93,  94 
Constipation,  during  pregnancy,  120 

in  infants,  529 
Contracted  pelvis,  measurements  in, 

29 
Convulsions,  in  infants,  531 
Cord,  umbilical,   76 
development  of,  61 
ligation   of,   272 
prolapsed,  285 


INDEX 


549 


Corpus  luteum,  49 

false,  49 

of  menstruation,  49 

of  pregnancy,  49 

verum,  49 
Corsets,  during  pregnancy,  121 

front-lace,  122 

maternity,  122 
Cow 's  milk  compared  with  mother  's 

milk,  491 
Cramps  in  legs,   during   pregnancy, 

140 
Cravings,  during  pregnancy,  127 
Cul-de-sac  of  Douglas,  36,  39 

Dammerschlaf,    292 

Date    of    confinement,    to    calculate, 

93,  94 
Deaths  in  childbirth,  112,  405 
Decidua  basalis,  66 

graviditatis,  65 

reflexa,   66 

serotina,  Q6 

vera,  66 
Deficiency  diseases,   372,   378 
Delivery,     dressings     required     for, 
159 

patient  draped  for,  262 

preparation  of  dressings  for,  155, 
158 
of  equipment  for,   155 
of  room  for,   155 

requirements   of   mother   for,    158 
of  physician  for,  161 

room  ready  for,  258,  259 
Detachment  of  placenta,  241 
Desserts  allowed  in  pregnancy,   128 
Development  of  cord,  61 

of   embryo,   61,   76,   78,   80 

of  fetus,  61,  76,  78,  80 

of   membranes,   61 

of  ovum,  61 

of  placenta,  61,  72 
Diameters  of  fetal  head,  90,  91 

of  pelvis,  25,  26,  27,  28 
Diarrhea,  during  pregnancy,  136 
Diarrheal  diseases  of  infants,  518 
Diastasis  of  rectus  muscles,  102 
Diet  during  pregnancy,  125,  128 

during  puerperium,  329 

of  nursing  mother,  363 
Digestive   tract,   changes   in   during 
pregnancy,  104 

during  puerperium,  321 
Discoloration  of   skin  during   preg- 
nancy, 97 
Discomforts  during  pregnancy,   134 
Discus  proligerus,   48 
Distress  during  pregnancy,  136 
Douches,  vaginal,  in  puerperium,  338 
Douglas,  cul-de-sac  of,  36,  39 


Dressings,  post-partum,  336 

required    for    delivery,    155,    158, 

159 
Dried  milk,  505 
Drugs  excreted  in  milk,  331 
Dry  labor,  235 

Dry  pack,  hot,  in  eclampsia,  197 
Ductless   glands,   changes   in   during 

pregnancy,  105 
Duncan 's    mechanism    of    placental 

separation,  239,  242 
Dysmenorrhea,  56 

Eclampsia,  190 

colonic   irrigations   in,   195 

frequency  of,  190 

mortality  of,  191 

nursing  care  in,  193 

symptoms  of,  191 

treatment  of,  193 
Ectoderm,   structures   derived   from, 

67 
Elevated  Sims'  position,  139 
Embryo,  67,  68 

development  of,  61,  76,  78,  80 
Embryonic  area,  66 

development,  67 
Emotional     changes     during     preg- 
nancy, 105 
Endometrium,   32 

premenstrual  swelling  of,  49 
Enema,  to  give  to  infant,  530 
Engagement  of  presenting  part,  224 
Engorgement    of    breasts,    in    new- 
born,  541 
Entoderm,   structures  derived  from, 

67 
Episiotomy,  298 

Equipment,   preparation   of   for   de- 
livery, 158 
Esbach's  test  for  albumen  in  urine, 

118 
Ether  anesthesia,  289,  290 
Evaporated  milk,  504 
Examination  of  eye,  method  of  hold- 
ing baby  for,  537 

of  urine,  in  pregnancy,  117 

rectal,  during  pregnancy,  231 

vaginal,  in  labor,  248,  252 
in  pregnancy,  230 
Excretions  during  pregnancy,  117 
Exercise,    bed,    during    puerperium, 
349 

for  nursing  mother,  364 

in  pregnancy,  129 
Expectant  mother,  110 

mental  hygiene  of,  145 
Extra-uterine  pregnancy,  82 

Face  presentation,  positions  in,  223 
Fallopian  tubes,  anatomy  of,  33 


550 


INDEX 


Fallopian  tubes,  changes  in  during 
pregnancy,  102 

fimbriae  of,  34 
Fat  soluble  A.  vitamines,  371,  377 
Feeder,  for  premature  babies,  513 
Feeding,   486 

artificial,  489 

breast,  486 

mixed,  503 

percentage,  499,  500,  501 
Feet,  swelling  of  during  pregnancy, 
137 

varicose    veins    of    during    preg- 
nancy,  138 
Fertilization,  62 
Fetal  circulation,  84,  85 

changes  in  at  birth,  84,  87 
Fetal  head,  88,  90 

circumference  of,  91 

diameters  of,  90,  91 

fontanelles  of,  89,  90 

rotation  of  during  birth,  236 

sutures  of,  89 
Fetal  heart,  auscultation  of,  231 
Fetal  heart  beat,  sign  of  pregnancy, 

99 
Fetal  mortality,  112 
Fetus,  68 

at  term,   80,   218 

attitude  of  in  uterus,  217 

bowels   of,   88 

development  of,  61,  76,  78,  80 

growth   of,   84 

head  of,  88,  90,  and  see  Fetal  head 

kidneys  of,  88 

maturation  of,  time  required  for, 
68 

movements   of,    as    sign   of   preg- 
nancy, 99 

palpation  of,  224 

as  sign  of  pregnancy,  99 

physiology  of,  84 

position  of,  217 

presentation  of,  217,  220 

presenting  part  of,  220 
Fimbria  ovarica,  34 
Flatulence  during  pregnancy,  136 
Follicle,  primordial,  47 
Fontanelles  of  fetal  head,  89,  90 
Foods  for  baby,  commercial,  503 

proprietary,    504 
Forceps,  300 

axis-traction,  301 

high,  303 

indications  for,  301,  302 

low,  303 

Simson's,  301 

Tarnier  's,  301 
Fornix  of  vagina,  35 
Fossa  navicularis,  40 
Fourchette,  40 


Frank  hemorrhage,  178 

Fresh  air  during  pregnancy,  129 

Front-lace   corset,   122 

Fruits    allowed    during    pregnancy, 

128 
Funis,  76 

Gastro-enteritis,  acute,  519 

nursing  care  in,  519 

symptoms  of,  519 

treatment  of,  519 
Gavage,  524 
Genitalia,  anatomy  of,  19 

external,  39 

internal,  30 
Germinal  spot,  48 

vesicle,  47 
Gonorrhea    complicating   pregnancy, 

212 
Gonorrheal  vaginitis  in  infants,  540 
Graafian  follicle,  34,  48 
Gymnastics  during  pregnancy,  130 

Harelip  in  newborn,  541 
Head,  fetal,  88,  90 

circumference  of,  91 

diameters  of,  90,  91 

fontanelles  of,  89,  90 

rotation  of  during  birth,  236 

sutures  of,  89 
Health,  general,   during   pregnancy, 

106 
Heart,    fetal,    auscultation    of,    231 

lesions  of  complicating  pregnancy, 
209 
Heart  beat,  fetal,  sign  of  pregnancy, 

99 
Heart  burn,  during  pregnancy,  135 
Heat  and  acetic  acid  test  for  albu- 
men in  urine,  118 
Hebotomy,  303 
Hemorrhage,  accidental,  178 

antepartum,  174 

concealed,   178 

during  pregnancy,  143 

during  puerperiuni,  391 

frank,  178 

postpartum,  286,  391 
causes  of,  391 
treatment  of,  392 
Hemorrhoids  during  pregnancy,  140 
Hernia,  in  newborn,  542 

inguinal,  543 

umbilical,  542 
Hot  dry  pack  in  eclampsia,  197 
Hygiene,  of  nursing  mother,  363 

of  pregnancy,  116 
Hysterotomy,  vaginal,  305 

Icterus,  in  newborn,  540 
Ignorance,  dangers  of,  546 


INDEX 


551 


Ilium,  19 
Impetigo,  540 
Impregnation,  62 
Inanition,  518 
Incomplete  abortion,  170 
Indian  binder  for  breasts,  347 
Induced  abortion,  309 

indications,    309 

methods,  310 
Infancy,  abnormalities  of,  518 

disorders  of,  518 

infection  in,  533 
Infant,  and  see  Newborn 

colic  in,  528 

constipation  in,  529 

convulsions  in,  531 

diarrheal  diseases  of,  518 

enema  for,  530 

gonorrheal  vaginitis  in,  540 

syphilis  in,  538 

vaginitis  in,  540 

vomiting  in,  532 

wasting  diseases  in,  518 
Infantile  scurvy,  374 
Infection,  in  infancy,  533 

puerperal,  393 

nursing  care  in,  399 
prevention  of,  399 
symptoms  of,  396 
treatment  of,  399 
Infusion,    of    orange   peel,   prepara- 
tion of,  506 

aaline,  in  eclampsia,  200 

under  breast,  202 
Inguinal  hernia,  in  newborn,  543 
Injection   of    salines,    in   eclampsia, 

200 
Innominate  bones,  19 
Instructions  to  patients,  427 
Intestinal  irrigations,  522 
Invalidism,  due  to  lack  of  obstetrical 

care,  112 
Involution  of  uterus,  317 
Irrigations,    colonic,    in    eclampsia, 
195 

intestinal,   522 
ischium,  20 

Itching  of  skin,   during  pregnancy, 
141 

Jaundice,  in  newborn,  540 

Kidneys,  during  pregnancy,  117 
of  fetus,  88 

Labia  majora,   39 

minora,   40 
Labor,  cause  of,  232 

cervix  during,  234 

complicated,   295 

course    of,    232 

definition  of.  232 


Labor,  dry,  235 
duration   of,   233 
first  stage  of,  233 

nurses   duties   during,   245,   256 
mechanism   of,  232 
nurses  duties  in,   243 

during  first  stage,  245,  256 
during  second  stage,  256 
during  third  stage,  278 
when  doctor  is  delayed,  283 
onset  of,   232 
pains  of,  232 
premature,   172 
causes  of,  172 
induced,  309,  310 
treatment,    173 
preparation  for,  248 
of  bed,  248 
of  room,  248 
signs    of,    232 
second  stage  of,  236 

nurses  duties  during,  256 
stages  of,  232 
symptoms  of,  232 
third  stage  of,  240 

nurses  duties  during,  278 
vaginal   examination   in,    252 
when  to  call  physician,  247 
Lactation,    320,    342 
Lactose,  498 
Lacerations,   perineal,   296 

repair  of,  297 
Lavage,  524 
Layette,    details    of,    162 

recommended  by  Maternal  Centre 
Association,  416 
Leg,   cramps   in   during   pregnancy, 

140 
Leg,  milk,  400 
Leg  straps,  to  improvise,  296 
Leggings,  for  delivery  or  operation, 

304 
Ligaments,  broad,  33,  38 
ovarian,  34,  38 
round,  38 
uterine,  38 
Ligation  of  cord,  272 
Linea  nigra,  197 
Linear  albicantes,   102 
Liquor  amnii,  71 

foliiculi,  48 
Liver,  acute  yellow  atrophy  of  dur- 
ing pregnane)',  207 
Lochia,  319 
alba,  319 
rubra,  319 
serosa,    319 
Longitudinal  presentations,  221 
Loss  of   weight   during   puerperium, 

319 
Lutein,   49 


552 


INDEX 


Malnutrition,   369,   387,  518 

Maltose,   498 

Mania,  puerperal,  400 

Marasmus,   518 

Marital  relations  during  pregnancy, 

133 
Masque    de    femmes    enceintes,    105 
Massage  during  pregnancy,  130 
Mastitis,   345 
Maternal  mortality,  112 
Maternity  Centre  Association,  410 

baby's  supplies,  428 

clinical  equipment,  432 

clinical  routine,  429 

doctor's   duties,  431 

duties  of  clinical  assistants,  431 

forms  and  routines  used  by,  423 

instructions  to  patients,  427 

mother  's  supplies,  428 

nurse 's  duties,  429 

nursing  visits,  424 

orders  for  nurses,  484 

post-natal  follow  up,  435 

records,  427,  431 

requirements,   432 
Maternity  Centre  Nurse,  413 
Maternity  Centre  orders  for  nurses, 
434 

antepartum,   484 

post-natal,  435 

post-partum,  435 
Maternity    corsets,    122 
Maternity   Protective   Committee   of 
the  Woman's  City  Club,  411 
Maternity  records,  427,  431 
Maternity     Service     Association     of 
Physicians   and   Hospital   Su- 
perintendents, 411 
Maternity  service  for  rural  communi- 
ties, 422 
Maternity      nursing,      visiting,      in 

Montreal,  445 
Maternity  work  of  Visiting  Nurses 
Society  of  Philadelphia,  439 

delivery  routine,  441 

equipment  for  bags,  439 

routine  after  delivery,  442 

routine  in  home,  440 

routine  technique,  439 
Maturation  of   fetus,  time  required 

for,  68 
Mauriceau's  maneuver,  299 
Measurements,  in  contracted  pelvis, 

29 
Meatus  urinarius,  37 
Membrana    granulosa,    48 
Membrane,  vitelline,  47 
Membranes,  development  of,  61 

examination   of,    280 
Menopause,  56 
Menorrhagia,  56 


Menstrual  cycle,  50 
Menstruation,   50 

cessation   of,   sign   of   pregnancy, 

96 
corpus  luteum  of,  49 
difficulties  of,  54 
during  puerperium,  320 
modifications  of,  56 
painful,  54 

relation  to  ovulation,  55 
vicarious,   56 
Mesoderm,  structures  derived  from, 

67 
Mental   changes    during   pregnancy, 
105 
hygiene  during  pregnancy,  145 
Micturition,    frequent,    as    sign    of 

pregnancy,  97 
Migration  of  ovum,  61 
Milk,   canned,   504 
certified,  490 
condensed,    504 
cow 's    compared    with    mother 's, 

491 
dried,    505 

drugs  excreted  in,  331 
drying  up  of,  366 
evaporated,   504 
mixtures,  formulas  for,  500,  501, 

503 
mother 's  compared  with  cow 's,  491 
pasteurized,   494 
powders,    505 

preparation  of  for  baby,  494 
reconstructed,  505 
top,    499 
Avhole,  499 
Milk  leg,  400 
Miscarriage,  165 

early  signs  of,  142 
Missed  abortion,  170 
Mixed  feeding,  503 
Mons  Veneris,  39 
Montgomery,  tubercles  of,  48 
Morning  sickness,  97,  135,  142,  181 
Mortality,  fetal,  112 

maternal,  112 
Morula,  64,  65 
Mother,    advice    for,    427 

care  of  by  visiting  nurses,  437 
expectant,  110 

mental  hygiene  of,  145 
milk    of    compared    with    that    of 

cow,  491 
nursing,   357 
bowels  of,  364 
diet   of,   368 
exercises   for,   364 
hygiene  of,  363 
recreation  for,  365 
rest  for,  364 


INDEX 


553 


Mother,  nutrition  of,  368 

requirements  of  for  delivery,  158 

supplies  for,  428 
Movements  of  fetus  a  sign  of  preg- 
nancy, 99 
^Multipara,  definition  of  term,  219 
Multiple  pregnancy,  82 


Nausea,  during  pregnancy,  134 
Nephritic     toxemia,     during     preg- 
nancy, 203 

nursing  care  of,  205 

symptoms  of,  204 

treatment  of,  205 
Neurotic     vomiting     during     preg- 
nancy, 183 
Newborn  baby  and  see  Infant 

abnormalities   of,   540 

bathing  of,  463 

behavior  of,  459 

bowels,  training  of,  482 

cephalhematoma  in,  541 

characteristics  of,  451 

chest,  455 

cleft   palate   in,   542 

clothes  for,  472 

club  foot  in,  541 

cord,  458 

dressing  of,  469 

crying   of,   484 

development  of,  452 

diapers  for,  475 

ear  pulling,  prevention  of,  483 

engorgement  of  breasts  in,  541 

exercise   for,   480 

fontanelles,  455 

fresh  air  for,  477 

growth  of,  453 

harelip  in,  541 

head,  455 

height  of,  455 

hernia  in,   542,   543 

icterus  in,  540 

inguinal  hernia  in,  543 

jaundice  in,  540 

nursing  care  of,  461 

resuscitation  of,  273 

ruminating,  prevention  of,  484 

schedule  for,   462 

size   of,   452 

skin  of,  459 

sore  eyes  in,  533 

stools  of,   456 

tears  of,  459 

teeth  of,  455 

thumb-sucking,  prevention  of,  482 

training  of,  482 

umbilical  hernia  in,  542 

urine  of,  456 

weight  of,  452,  453 


Newborn  baby,  weight  chart,  454 
Nipples,  41 

care  of,  during  pregnancy,   132 
care  of,   in   puerperium,   340,  342 
cracked,  care  of,  342 
flat,  132 
retracted,  132 
toughening,  132 
Nipple  shields,  340,  341,  342 
Nitrous  oxid  gas  anesthesia,  291 
Nullipara,  definition  of  term,  219 
Nurses'  bag,  contents  of,  434 
Nurses'  duties,  in  clinic,  429 
during  labor,  243 
first  stage,  245,  256 
second  stage,  256 
third  stage,  278 
maternity   centre   orders   for,   434 
ante-partum,  434 
post-natal,  435 
post-partum,  435 
Plunkett,  408 

requirements  of  for  delivery,  161 
visiting,  care  of  mother  and  baby 

by,  437 
work  of  in  prenatal  ease,  112 
Nursing  mother,  357 
bowels  of,  364 
diet  of,  363 
exercise  for,  364 
hygiene    of,    363 
recreation  for,  365 
rest  for,  364 
Nursing  of  baby,  see  Lactation  and 
Nursing  mother 
frequency  of,  361 
methods   of,   358 
Nursing    care    in    puerperium,    32^3, 

326 
Nursing  visits,  424 
Nutrition,  369 
of  baby,  368 
of  mother,  368 

Oatmeal  Avater,  preparation  of,  506 
Obstetrical  anesthesia,  286,  288 

operations,   295 
Oocyte,  47 

Operating  table,  to  make,  295 
Operations,  destructive,  309 

obstetrical,  295 
Ophthalmia  neonatorum,  533 

nursing  care  of,  535 

symi)toms  of,  534 

prevention  of,  534 

treatment  of,  535 
Orange  juice,  ])reparation  of,  505 
Organized   ])renatal  work,   405 
Organs  of  reproduction,  female,  30 
Ossa  innoniinata,  19 
Ova,  34,  47 


554 


INDEX 


Ovarian  ligament,  34,  38 
Ovaries,  34 

changes  in  during  pregnancy,  102 
Ovulation,  47 

relation  to  menstruation,  55 
Ovum,  47,  68 

development  of,  61 

migration    of,    61 

segmentation  of,  64,  65 

Pack,  to  give,  521,  522 
Palpation  of  fetus,  224 

sign  of  pregnancy,  99 
Pasteurized  milk,  494 
Pellagra,  380 
Pelvic  cavity,  22 
Pelvic    examination    in   puerperium, 

329 
Pelvimetry,   19,  25,  and  see  Diam- 
eters of  pelvis 
Pelvis,  anatomy  of,  19 

brim    of,    22 

contracted,  measurements  of,  29 

diameters    of,    25,    and    see    Dia- 
meters of  pelvis 

false,  23 

female,  19,  21,  30 

inferior  strait,  23 

inlet,  22 

male,  21,  30 

measurements  of,  25 

normal  female,  19,  30 

outlet   of,   23 

rachitic,  30 

true,  23 
Pemphigus,   540 

Percentage  feeding,  499,  500,  501 
Perineal    dressings,    in    puerperium, 
336 

lacerations,  296 
repair  of,  297 
Perineum,  anatomy  of,  40 

care  of  in  puerperium,  335 
Peritoneum,  34 

Pernicious    vomiting    of    pregnancy, 
134,  181 

classification,  182 
Phlegmasia   alba    dolens,    400 
Physician,  requirements  of  for  deliv- 
ery,   161 

when  to  call  in  labor  cases,  247 
Physiology,  45 
Pigmentation,    in    pregnancy,    103, 

105 
Placenta,  68,  72 

delivery  of,  279 

detachment   of,   241 

development    of,    61,    72 

examination    of,    280 

function  of,  73 

origin  of,  72 


Placenta,  separation  of,  239,  279 
mechanism   of,   239,   241,   242 
premature,  178 
size  of,  75 
weight  of,   75 
Placenta  praevia,  174 
causes  of,  176 
central,  176 
complete,  176 
frequency  of,  174 
incomplete,  176 
marginal,  176 
mortality  in,  174 
partial,  176 
symptoms  of,  176 
treatment  of,  177 
Phmkett   nurses,    408 
Poncho,  Sutton  's,  479 
Position  of  fetus,  217 

definition  of,   221 
Position,    elevated    Sims,    139 

right  angled,  138 
Positions,  in  face  presentations,  223 
in    transverse    presentations,    223 
in  vertex  presentations,  222 
Post-natal    follow-up,    routine     for, 

435 
Post-natal  work  of  Maternity  Centre 

nurses,  419 
Post-partum  care  by  visiting  nurses, 
437 
dressings,   336 
hemorrhage,    286,    391 
causes  of,  391 
treatment  of,  392 
Potato  water,  preparation  of,  505 
Pouting  umbilicus,  103 
Powders,   milk,   505 
Pre-.eclamptic  toxemia,  187 
prevention  of,  188 
nursing  care  in,  189 
symptoms  of,  187 
treatment  of,   189 
Pregnancy,   abdominal  binders  dur- 
ing, 122 
abdominal  changes   in,   98,   102 
abdominal    enlargement,    sign   of, 

98 
accidents  of,  164 

acute  yellow  atrophy  of  liver  dur- 
ing, 207 
alcohol  during,  127 
bathing  during,  119 
bones,  changes  in  during,  104 
bowels,  care  of  during,  120 
breasts,  care  of  during,  131 
changes  in  a  sign  of,  96 
changes  in  during,  96,  103 
breast-binders  during,  123 
cardiovascular  system,  changes  in 
during,  103 


INDEX 


555 


Pregnancy,  carriage  in,  105 

cervix,  changes  in  during,  !)9,  1 02 
softening,  a  sign  of,  99 

cessation  of  menstruation,  a  sign 
of,  96 

clothes,  during,  121 

complications  of,  164 
early  signs  of,  141,  143 

constipation  during,   120 

corpus   luteum   of,   49 

corsets   during,   121 

cramps   in  legs   during,   140 

cravings  during,  127 

diarrhea    during,    136 

diet   during,    125,   128 

digestive    tract,    changes    in    dur- 
ing, 104 

discoloration  of  skin,  as  sign  of, 
97 

discomfort  during,  134 

distress  during,  136 

ductless    glands,    changes   in    dur- 
ing, 105 

duration  of,   93 

emotional  changes  during,  105 

excretions  during,   129 

exercise  during,  129 

extra-uterine,   82 

fallopian   tubes,    changes   in   dur- 
ing, 102 

fetal  heart  beat,  a  sign  of,  99 

fetal  movements  a  sign  of,  99 

flatulence  during,  136 

fresh  air  during,  129 

gonorrhea  complicating,  212 

gymnastics  during,  130 

health,  general,  during  pregnancy, 
106 

heartburn  during,  135 

heart  lesions  complicating,  209 

hemorrhage  during,  143 

hemorrhoids  during,   140 

hygiene  of,  116 

itching  of  skin  during,  141 

kidneys  in,  117 

marital  relations  during,  133 

massage  during,  130 

mental  changes  during,  105 

mental  hygiene  during,  145 

micturition,   frequent   as   sign   of, 
97 

morning  sickness  during,  97,  135, 
142,   181 

multiple,   82 

nausea  during,  134 

nephritic  toxemia  in,  203 

neurotic  vomiting  in,  147 

nipples,  care  of  during,  132 
flat,   132 
retracted,  132 

ovaries,  changes  in  during,  102 


Pregnancy,  palpation  of  fetus,  sign 
of,  99 
pernicious   vomiting   of,    134,    181 
pliysiology  of,  93,   100 
pigmentation  in,  105 
positive  signs  of,  99 
premature  termination  of,  165 

early   signs   of,    142 
presumptive  signs  of,  96 
pressure   symptoms  during,   137 
probable  signs  of,  98 
pulmonary     tuberculosis     compli- 
cating, 209 
psychoses  during,  147 
pyelitis  complicating,  212 
quadruplet,  82 
quickening,  as  sign  of,  98,  99 

to  calculate  date  of  confinement 
from,  94 
quintuplet,  82 
rectal  examination  in,  231 
respitary  organs,  changes  in  dur- 
ing,   104 
rest  during,  130 
sextuplet,  82 
shoes  during,  124 
shortness  of  breath  during,  140 
signs   of,   93 

positive,   99 

presumptive,    96 

probable,  98 
skin,   care   of   during,   118 

changes    in    during,    104 

itching  of  during,  141 

stretching  of  during,  141 
sleep    during,    130 
spurious,  96 

stocking  supporters  during,  124 
supporters,  abdominal,  during,  122 

stocking,  during,  124 
swelling  of  feet  during,  137 
symptoms  of,  93 
syphilis,  complicating,  207 
teeth   in,    104,    133 
temperature  of  body  in,  105 
thyroidism   complicating,  210 
toxemias  of,  142,  179 

early   signs   of,    142 
travelling   during,  133 
triplet,  82 
twin,  82 

umbilicus,  changes  in  during,  103 
urinary  apparatus,  changes  in  dur- 
ing, 104 
urine  in,  117 

tests    for,    118 
uterus,  changes  in  during,  101,  83 

sign  of,  98,  99 
vagina,  ciiangos  in  during,  102 
vaginal  discharge  during,  140 

examination  in,  230 


556 


INDEX 


Pregnancy,    varicose    veins    during, 
138 

vomiting  during,  134,  181 
Premature  baby,  508 

bed   for,    512 

care  of,  509 

feeder   for,   513 

feeding  of,   510,   513 

heat  required  for,  511,  512 

size  of,  508 
Premature  labor,  172,  165 

causes  of,  172 

early  signs  of,  142 

induced,   309,   310 

indications  for,  310     . 
methods,  311 

treatment  of,  173 
Premature    separation    of    normally 
implanted  placenta,  178 

causes   of,   178 

symptoms  of,  178 

treatment  of,  179 
Premature      termination      of     preg- 
nancy,  165 
early  signs  of,  142 
Premenstrual   swelling    of    endomet- 
rium, 49 
Prenatal  care,  111 

work  of  nurse  in,  112 
Prenatal  work,  organized,  405 
Prenatal  visits,  routine  for,  423 
Preparations  for   delivery,   155,   158 
Presentation  of  fetus,   217 

definition  of,  220 

face,  223 

longitudinal,    221 

transverse,   221,    223 

vertex,  222 
Presenting   part,   definition   of,    220 

engagement  of,  224 
Pressure     symptoms     during     preg- 
nancy, 137 
Prickly  heat,  516 
Primigravida,  definition  of,  219 
Primipara,  definition  of,  219 
Primordial  follicle,  47 
Prolapsed   cord,   285 
Proprietary  baby  foods,  504 
Protein  milk,  preparation  of,  506 
Pseudocyesis,  96 
Psychoses  during  pregnancy,  147 
Puberty,  45 
Pubiotomy,  304 
Pubis,  20 

Pudendal  crease,  39 
Puerperium,  317 

abdominal  binder,   in,   349 

abdominal  wall  in,  321 
.  bath  in,  329 

bed  exercise  in,  349 

bladder,  care  of  during,  332 


Puerperium,  boAvels,  care  of  during, 
331 
bradycardia  during,  322 
breasts,  binder  for,  345,  347 
care  of  during,  339 
supports  for  during,  343,  345 
complications  in,  391 
diet  in,  329 

digestive   tract   during,   321 
douches,  vaginal  during,  338 
hemorrhages    during,   391 
infection  in,  393 
nursing  care  of,  399 
symptoms  of,  396 
treatment  of,  399 
loss  of  weight  during,  319 
mania   during,   400 
menstruation  during,  320 
nipples,  care  of  during,  340 
nursing  care  in,  323,  326 
pelvic  pxamination  in,  329 
perineal  dressings  in,  336 
perineum,  care  of  during,  335 
physiology  of,  317 
pulse  during,  322,  335 
jDOsition  in  bed   during,  326 
respiration  in,  335 
sitting  up  in,  328 
skin   in,   322 
temperature  in,  321,  335 
urine  in,  322 

uterus,  changes  in  during,  317 
height  of  during,  327,  328 
Puhnonary  tuberculosis  complicating 

pregnancy,  209 
Pulse,  in  puerperium,  322,  335 
Pyelitis      complicating      pregnancy, 
212 

Quadruplet  pregnancy,  82 
Quickening,    as   sign   of   pregnancy, 

98,  99 
to  calculate  date  of  confinement 
from,    94 
Quintuplet  pregnancy,  82 

Rachitic  pelvis,  30 
Reconstructed   milk,   505 
Records,    maternity,   427,   431 
Recreation,  for  nursing  mother,  365 
Rectal    examinations,    during    preg- 
nancy, 231 
Rectum,  37 
Reflex   vomiting    during    pregnancy, 

182 
Reproduction,  organs  of,  30 
Respiration,  in  puerperium,  335 
Respiratory  organs,  changes  in  dur- 
ing  pregnancy,   104 
Rest,  during  pregnancy,  130 
for  nursing  mother,  364 


INDEX 


557 


Resuscitation  of  newborn  baby,  273 
Richardson  Y  binder,  345,  347 
Rickets,   381 

symptoms  of,  382 

treatment  of,  385 
Right  angled  position,  138 
Room   for   delivery,   preparation   of, 

155,   258,   259 
Rotation  of  fetal  head  during  birth, 

236 
Round  ligaments,  38 
Routine  for  prenatal  visits,  423 
Rubl)er  gloves,  sterilization  of,  253 
Kuminating   cap,   485 
Huinination,  prevention  of,  484 
Ruptured  uterus,  307 

causes    of,    308 

frequency   of,   308 

symptoms  of,  308 

treatment  of,  308 

Saero-eoecygeal  joint,  20 

Sacro-iliac  joints,  20 

Sacro-vertebral  joint,   22 

Sacrum,  20 

Saline  infusion,  in  eclampsia,  200 

Schenk  's   theory    of    sex    determina- 
tion, 63 

Schultze's    mechanism    of    placental 
separation,  239,  241 

Scopolamin  and  morphin  anesthesia, 
292 

Scorbutus,  373 

Scurvy,   373 
infantile,  374 

Segmentation    of    ovum,    04,    65 

Separation  of  i)lacenta,  239,  279 
mechanism  of,  239,  241,  242 

Sex,    determination    of,   theories   of, 
63 

Sextuplet  ])regnanoy,  82 

Shoes,    during    j)regn:iiu'y,   124 

Shortness    of    breath,    during    preg- 
nancy, 140 

' '  Show, ' '  235 

Sims'  elevated  position,  139 

Simson's  forceps,  301 

Sinciput,  89 

Sitting  up,  during  puerperium,  328 

Skin,  care  of  in  pregnancy,  118 
changes  in,  during  pregnancy,  97, 

104 
discoloration  of  as  a  sign  of  preg- 
nancy,   97 
in  puerperium,  322 
itching  of,  during  pregnancy,  141 
stretching    of,    during   pregnancy, 
141 

Sleep,  during  pregnancy,  130 

Society   for  the   Health   of   Mothers 
'and  Children,  408 


Soda  bath,  preparation  of,  517 

Soups,    allowed    during    pregnancy, 
128 

Spermatozoa,  61,  62 

Sphincter   ani,   37 

Spinach,   preparation    of,   505 

Sprue,   539 

Spurious  pregnancy,  96 

Starch  bath,  preparation   of,   517 

Stocking    supporters    during    preg- 
nancy, 124 

Stretching     of    skin,    during     preg- 
nancy, 141 

Stria?,    97,  "102 
gravidarum,  102 

Stripping    of    breast,    348 

Subcutaneous    injection    of    salines 
in  eclampsia,  200 

Sucking    of    thumb,    prevention    of, 
482 

Sugar,   498 

Summer,   care   of  baby  during,   514 
complaint,    519 
diarrhea,  519 

Supplies  for  baby,  428 
for  mother,  428 

Supporter,   abdominal,   during  preg- 
nancy,  122 

Supi^orts  for  breasts,  in  puerperium, 
343,    345 

Sutton's  poncho,  479 

Sutures  of  fetal  head,  89 

Swelling  of  feet  during  pregnancy, 
137 

Symphysiotomy,  305 

Syphilis,     complicating     pregnancy, 
207 
in   infants,   538 


Tarnier's    forceps,    301 
Teeth,    care    of    during    pregnancy, 
133 

in  pregnancy,   104,   133 
Temperature,  in  pregnancy,  105 

in   puerperium,   335 
Tests  for   albumen   in   urine,   118 
Theca  folliculi,   48 
Therapeutic    abortion,    171 
Threatened  abortion,  170 
Thrush,    539 

Thumb  sucking,  to  prevent,  482 
Thyroidism  complicating  pregnancy, 

210 
Toilet  tray,  baby's,  417 
Tomato  juice,  to  prepare,  506 
Top    milk,    499 
Toxemia,  nephritic,  203 

nursing  care  in,  205 

symptoms  of,  204 

treatment   of,  205 


558 


INDEX 


Toxemia,  pre-eclamptie,  187 

nursing  care  of,  189 

prevention  of,  188 

symptoms  of,  187 

treatment  of,  189 
Toxemias  of  pregnancy,  142,  179 

early  signs  of,  142 
Toxemic     vomiting,     during     preg- 
nancy,  184 
Transverse   presentations,   221 

positions  in,  223 
Travelling,  baby  basket  for,  507 

care  of   baby   in,   507 

during  pregnancy,  133 
Triplet  pregnancy,  82 
Tubercles   of  Montgomery,   43 
Tuberculosis,   pulmonary,   complicat- 
ing pregnancy,  209 
Twilight  sleep,  292 
Twin    pregnancy,    82 

Umbilicus,  changes  in  during  preg- 
nancy, 103 
pouting,  103 
Umbilical  cord,  76,  and  see  Cord 
Umbilical  hernia,  in  newborn,  542 
Ureters,    37 
Urethra,  37 

Urinary  apparatus,  changes  in  dur- 
ing pregnancy,  104 
Urine,  albumen  in,  to  test  for,  118 
in  pregnancy,  117 

examination  of,  117 
in  puerperium,  322 
to  obtain  specimen  of  from  baby, 
526,  527 
Uterus,  anatomy  of,  30 
blood  supply  of,  32 
body    of,    32 
cervix  of,  32,  33, 

changes  in  during  pregnancy.  83, 
98,    101 
as  sign  of  pregnancy,  98 
changes  in  during  puerperium,  317 
contractions   of   as   sign   of   preg- 
nancy, 99 
cornua    of,    33 
external  os,  33 
fundus,  32 

height  of  in  puerperium,  327,  328 
internal  os,  33 
involution  of,  317 
ligaments  of,  33,  38 
muciparous,  32 
ruptured,  307,   and  see   Ruptured 

uterus 
virgin,  32 

Vagina,    changes    in    during    preg- 
nancy, 102 
fornix  of,  35 


Vaginal  discharge  during  pregnancy, 
140 

douches    during    puerperium,    338 

examination  in  labor,   248,  252 
in  pregnancy,  230 

hysterotomy,  305 

opening,  40 
Vaginitis,    in    infants,    540 
Varicose    veins    during    pregnancy, 

138 
Vegetables     allowed     during     preg- 
nancy, 128 
Venesection  in  eclampsia,  200 
Version,  299 

cephalic,  299 

combined,   300 

external,  300 

indications,  299 

internal,    300 

podalic,  300 
Vertex    presentations,    positions    in, 

222 
Vestibule,  40 

Vicarious    menstruation,    56 
Villi,  chorionic,  68,  70 
Visiting  nurses,  care  of  mother  and 

baby  by,  437 
Vitamiues,    371 

fat   soluble  A.,  371,  377 

water  soluble  B.,  371,  377 

water  soluble  C,  371,  373 
Vitelline  membrane,  47 
Vomiting     during     pregnancy,     134, 
181 

pernicious,  134,  181 

neurotic,  147,  183 

reflex,  182 

toxemic,  184 
Vomiting  in  infants,  532 
Voorhees'  bag,  312 
Vulva,  39 

cleansing  of,  249 

varicose    veins    of    during    preg- 
nancy, 139 

Wassermann's    reaction,    in    obstet- 
rics, 208,  209 
Wasting   diseases  of   infants,   518 
Water  soluble  B.,  371,  377 
Water  soluble  C,  371,  373 
Weaning,   365 
Weight,  loss  of,  during  puerperium, 

319 
Weight   of  newborn  baby,  452,  453 

chart,    454 
Whey,   preparation   of,   506 
Whole   milk,   499 
Woman's   Municipal  League,  409 

Xerophthalmia,  377 


THIS  BOOK  IS  DUE  ON  THE  LAST  DATE 
STAMPED  BELOW 


AN  INITIAL  FINE  OF  25  CENTS 

WILL  BE  ASSESSED  FOR  FAILURE  TO  RETURN 
THIS  BOOK  ON  THE  DATE  DUE.  THE  PENALTY 
WILL  INCREASE  TO  SO  CENTS  ON  THE  FOURTH 
DAY  AND  TO  $I.OO  ON  THE  SEVENTH  DAY 
ERDUE. 


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1934 


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APR  '>  7  1949 


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LD  21-100m-7,'33 


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^ 


UNIVERSITY  OF  CALIFORNIA  UBRARY 


